Incomplete PASARR Assessment for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) was completed accurately and that all relevant mental health diagnoses were included. The resident was admitted with diagnoses including diffuse traumatic brain injury, bipolar disorder, and major depressive disorder. Documentation review showed that the PASARR Level I screening did not reflect the resident's diagnosis of major depressive disorder, despite this diagnosis being present in the medical record and care plan. The PASARR indicated that a referral for a Level II evaluation was not necessary, based on incomplete information. Interviews with facility staff, including a medical social worker and the Director of Nursing, confirmed that the PASARR assessment did not accurately list all of the resident's mental health diagnoses. The facility's policy required that all mental health-related diagnoses be reflected in the PASARR assessment and that individuals meeting criteria for a mental disorder be referred for further evaluation. The omission of the major depressive disorder diagnosis on the PASARR resulted in the resident not being properly evaluated for specialized services.