Failure to Accurately Complete and Review PASARR Level I for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to properly coordinate and complete the Preadmission Screening and Resident Review (PASARR) Level I process for three residents with serious mental illness diagnoses. For one resident, the facility did not review the PASARR Level I submitted by another facility upon admission, despite the resident having diagnoses of paranoid schizophrenia, schizoaffective disorder, depression, and anxiety, as well as exhibiting behavioral issues such as banging her head on the wall. The resident was also prescribed multiple psychotropic medications, and her Minimum Data Set (MDS) indicated severely impaired cognitive skills and the need for assistance with daily activities. The Minimum Data Set Nurse (MDSN) acknowledged that a new PASARR Level I should have been submitted due to significant changes in the resident's condition and behaviors, and that the lack of review could have resulted in missed recommendations for specialized care. For two additional residents, both with documented diagnoses of serious mental illness and prescribed psychotropic medications, the PASARR Level I screenings were completed but inaccurately indicated negative results for serious mental illness. The MDSN confirmed that these screenings should have been positive based on the residents' diagnoses and medication regimens. The facility's policy requires accurate completion and review of PASARR Level I to ensure appropriate care planning and access to specialized services for residents with mental illness or intellectual disabilities. Interviews with facility staff, including the MDSN and Director of Nursing (DON), revealed that the interdisciplinary team is responsible for reviewing PASARRs for accuracy and returning them for correction if necessary. However, in these cases, the PASARRs were not properly reviewed or completed, resulting in the potential for residents not receiving the necessary care and services tailored to their mental health needs.