Failure to Identify Mental Illness on PASRR Level I Screenings
Penalty
Summary
The facility failed to accurately identify and document mental illness diagnoses on the Preadmission Screening and Resident Review (PASRR) Level I assessments for three residents. Specifically, two residents with major depressive disorder and one resident with schizoaffective disorder and bipolar disorder were not recognized as having a mental illness on their PASRR Level I screenings, despite clear documentation of these diagnoses in their medical records, medication orders, and care plans. The PASRR Level I forms for all three residents indicated 'No' in response to the question regarding evidence of mental illness, which was inconsistent with other clinical documentation. Record reviews showed that each resident had a documented diagnosis of a qualifying mental illness and was receiving psychotropic medications for these conditions. The Minimum Data Set (MDS) assessments and care plans for these residents also reflected their psychiatric diagnoses and related interventions. However, the PASRR Level I screenings did not reflect this information, resulting in a lack of appropriate identification for further evaluation or services as required by PASRR regulations. Interviews with facility staff revealed a lack of understanding regarding the correct completion of PASRR Level I screenings, particularly in cases where residents had documented mental illness diagnoses. The MDS nurse and DON both indicated that hospital PASRR assessments were often submitted without updates to reflect current diagnoses, and that negative PASRR Level I results were routinely accepted even when residents were on psychotropic medications for mental illness. The facility's policy required coordination with local authorities for further evaluation when a PASRR Level I indicated possible mental illness, but this process was not followed due to the inaccurate screenings.