Failure to Complete Required PASARR for Resident with Mental Health Diagnosis
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) was completed for one of three sampled residents with a diagnosis of bipolar disorder, anxiety, and heart failure. The resident was re-admitted to the facility and had a care plan indicating consideration for a Level II PASARR, with paperwork submitted for review. However, a review of the medical record revealed no evidence that a Level I PASARR had been updated or completed, despite the resident residing in the facility for over 30 days. The resident's clinical record included a diagnosis of bipolar disorder, a physician's order for Trileptal for bipolar disorder, and a BIMS score indicating moderately impaired cognition. Interviews with the Social Service Director, Social Worker, and DON revealed inconsistent understanding and application of PASARR requirements. The Social Service Director stated that PASARR reviews are conducted upon admission and as needed, but also indicated that, based on the resident's diagnosis and behavior, there was no need for a PASARR to be completed. The DON reported that PASARRs had been completed on several previous dates but did not provide evidence of a current or updated Level I PASARR for the resident. Facility policy requires completion of a Level I PASARR before or at admission and timely requests for Level II PASARR when indicated, which was not followed in this case.