Failure to Complete Accurate PASARR Screenings for Residents with Mental Illness or Intellectual Disability
Penalty
Summary
The facility failed to ensure that Level I and Level II Preadmission Screening and Resident Review (PASARR) screenings were accurate and complete for 12 out of 14 sampled residents. Multiple residents were admitted with diagnoses such as bipolar disorder, schizoaffective disorder, major depressive disorder, generalized anxiety disorder, and other serious mental illnesses, yet their PASARR Level I screens either did not reflect these diagnoses or failed to indicate the need for a Level II evaluation. In several cases, the PASARR forms were incomplete, blank, or missing critical information, and no Level II PASARR was conducted despite qualifying diagnoses and evidence of functional impairment due to mental illness. Interviews with the Director of Nursing (DON) revealed that the facility's process for handling PASARR screenings was inconsistent and lacked oversight. The DON confirmed that PASARRs were not always available upon admission and that the responsibility for completing and updating PASARRs was assigned to social services staff, who were not consistently present or available. The DON also acknowledged that she did not verify the accuracy or completion of PASARRs and that there was no current access to the PASARR system by facility staff, resulting in delays or omissions in required screenings and referrals for Level II evaluations. The medical records reviewed showed that residents with significant psychiatric and behavioral diagnoses were not properly identified in the PASARR process, and in some cases, residents were receiving psychotropic medications and behavioral interventions without the required PASARR documentation. Facility policy required prompt referral for Level II PASARR when a serious mental disorder or intellectual disability was identified, but this was not consistently followed. The lack of accurate and timely PASARR screenings led to residents with serious mental illness or intellectual disability not being properly evaluated as required by federal regulations.