Failure to Complete and Document PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) process was properly completed and documented for two residents with mental health diagnoses. For one resident admitted with depression, schizoaffective disorder, anxiety, psychosis, and insomnia, the facility did not resubmit a new Level I PASARR screening as required after an exempted hospital discharge. The resident's records indicated ongoing needs for nursing staff assistance with daily activities and the ability to make healthcare decisions, but the necessary PASARR review to determine appropriate services was not completed. For another resident with a diagnosis of schizophrenia, the PASARR Level I screening was documented incorrectly, indicating the resident did not have schizophrenia, despite medical records stating otherwise. This resident also required significant assistance from nursing staff for daily care. Interviews with facility staff confirmed that the PASARR screenings were either not completed or documented incorrectly, and that these omissions could affect the care and services provided to the residents. The facility's policy required coordination with the PASARR program and prompt referral for Level II review upon significant changes, but these procedures were not followed in these cases.