Failure to Complete PASRR Level II Assessment After Short-Term Approval
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a PASRR Level II assessment was completed for a resident with a suspected serious mental illness following an exempted short-term approval. The resident, who had diagnoses including chronic obstructive pulmonary disease and bipolar disorder, was admitted with a 7-day emergency short-term post-hospital discharge approval for PASRR Level I. The Level I screen recommended a re-screen and, if necessary, a Level II evaluation by the seventh day if the resident remained in the facility. The resident was discharged to an acute care hospital and later readmitted to the facility. However, documentation showed that the Level II evaluation, initially requested, was cancelled due to the resident's hospital discharge, and no follow-up referral for a Level II assessment was made upon the resident's readmission. The facility's PASRR episode tracker did not indicate that a Level II PASRR was completed after the resident's return. The social worker responsible for tracking PASRR evaluations acknowledged that the follow-up referral was not made due to oversight. The Director of Nursing Services confirmed the expectation that PASRR referrals should be completed as recommended. No facility policy related to PASRR referrals was provided upon request.