Failure to Refer Resident with Mental Health Diagnoses for PASRR Level II Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with multiple qualifying mental health diagnoses was referred for a Level II Preadmission Screening and Resident Review (PASRR). The resident was admitted with diagnoses including bipolar II disorder, obsessive-compulsive behavior, major depressive disorder, anxiety disorder, and psychosis. Review of the resident's records, including the Annual Minimum Data Set (MDS) and care plan, confirmed the presence of these diagnoses and the use of antipsychotic medications. However, there was no evidence in the clinical record of a PASRR Level II evaluation being completed or submitted. Interviews with facility staff, including the Admissions Coordinator, DON, and Administrator, confirmed that the PASRR Level I screening was completed and present in the record, but the required Level II referral for residents with qualifying diagnoses had not been made. The DON and Administrator both acknowledged that the resident met criteria for a Level II PASRR and that it was the responsibility of the Social Worker to ensure the referral was submitted. No documentation could be provided to show that a PASRR Level II had been requested or completed for this resident.