Failure to Complete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
A deficiency occurred when the facility failed to submit a Pre-admission Screening and Resident Review (PASARR) for one of four sampled residents. The resident in question was admitted with diagnoses including schizophrenia, major depressive disorder, anxiety, and other persistent mood disorders. Review of the resident's Minimum Data Set (MDS) indicated severely impaired cognitive skills and a need for maximal assistance with activities of daily living. Despite these significant mental health diagnoses, there was no evidence that a Level 1 PASARR was completed upon admission as required. During an interview and record review, the DON confirmed that PASARR screenings are to be completed before or within 24 hours of admission, but acknowledged that the process was not followed for this resident. The DON also stated she had the capability to process PASARRs but had not been given access to do so. The facility's policy, dated December 2022, requires PASARR Level 1 screening for all potential skilled nursing facility residents, but this protocol was not adhered to in this case.