Failure to Complete PASARR Level I Screening After Psychiatric Hospitalization
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) Level I screening was completed for a resident with multiple mental health diagnoses following two hospitalizations for crisis states involving violent and aggressive behaviors. The resident, who had a history of Major Depressive Disorder, Mood Disorder, Adjustment Disorder with Mixed Anxiety and Depressive Mood, Bipolar Disorder, and HIV, was admitted, discharged under a [NAME] Act due to behavioral crises, and subsequently readmitted to the facility on two occasions. Despite these significant events and changes in the resident's mental status, the only PASARR Level I on file was dated prior to the hospitalizations, and no new PASARR Level I was completed upon the resident's readmissions. Review of the facility's policy indicated that it is the responsibility of the center, specifically the Social Services department, to ensure that appropriate PASARR screenings are conducted and documented prior to admission or readmission, and that significant changes trigger updated screenings. Interviews with the Director of Social Services and the regional nurse confirmed that the required PASARR Level I was not completed after the resident's returns from the hospital, and there was no documentation or assessment by Social Services regarding the [NAME] Act discharges during the relevant period.