Failure to Accurately Complete PASRR Documentation for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Reviews (PASRR) were accurately completed for all residents reviewed for mood and behavior disorders. Specifically, for seven residents, the PASRR documentation did not reflect the presence of serious mental illness or intellectual disability, despite clinical records and physician orders indicating diagnoses such as anxiety disorder, major depressive disorder, psychosis, bipolar disorder, schizoaffective disorder, PTSD, and other psychiatric conditions. In several cases, residents were prescribed multiple psychotropic medications for these conditions, yet their PASRR forms did not acknowledge any mental illness. For example, one resident was readmitted with diagnoses including anxiety disorder, major depressive disorder, and psychosis, and was prescribed medications such as Xanax and Zoloft, but the PASRR did not document any serious mental illness. Another resident had a history of bipolar disorder and major depressive disorder, with physician orders for Depakote, aripiprazole, escitalopram, Remeron, and buspirone, and a psychiatry note referencing schizoaffective disorder, yet the PASRR failed to indicate any mental illness. Similar discrepancies were found for other residents, where clinical documentation and medication orders clearly indicated mental health diagnoses, but the PASRR forms either omitted these diagnoses or only partially documented them. Interviews with facility leadership, including the DON and Administrator, confirmed that the PASRRs were not completed accurately and did not include all applicable diagnoses. The Administrator acknowledged the inaccuracies and stated an expectation that PASRRs should be correct. The findings were based on both record review and staff interviews, highlighting a pattern of incomplete or inaccurate PASRR documentation for residents with significant mental health needs.