Failure to Implement PASRR Level II Neurocognitive Evaluation Recommendation
Penalty
Summary
The facility failed to incorporate and arrange for the recommendations outlined in the Pre-Admission Screening and Resident Review (PASRR) Level II determination for a resident with a diagnosis of major depressive disorder. Specifically, the PASRR Level II evaluation recommended that the resident receive a neurocognitive evaluation to assess cognitive functions and the impact of neurological conditions. However, the resident's care plan did not include this recommendation, and there was no physician order or documentation indicating that a neurocognitive evaluation had been scheduled or completed since the resident's admission. Record review showed that the resident was cognitively impaired and had a history of dementia and major depressive disorder, with ongoing use of antidepressant medications. Despite the PASRR Level II recommendation, progress notes and computerized physician orders lacked any reference to a neurocognitive evaluation. Staff interviews confirmed that the social services director was responsible for implementing PASRR recommendations but was unable to find evidence that the evaluation had been arranged or performed. The only related documentation was a behavioral health progress note by a licensed clinical social worker, which did not meet the requirements for a neurocognitive evaluation as defined by professional standards.