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F0645
D

Failure to Complete PASARR for Resident with Mental Disorder

Jesup, Georgia Survey Completed on 05-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident with a mental disorder. Record review showed that the resident was admitted with diagnoses including bipolar disorder, manic episode, and generalized anxiety disorder. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment. Although a PASARR Level I was completed at admission, there was no evidence of a PASARR Level II in the resident's electronic medical record, despite the presence of a qualifying mental health diagnosis. Interviews with facility staff, including the Social Service Director (SSD), Business Office Manager (BOM), and Administrator, revealed a lack of understanding and knowledge regarding the PASARR process, particularly in situations involving significant changes in a resident's mental or physical condition. The staff believed that PASARRs were only completed upon admission and that hospitals or behavioral health units were responsible for subsequent screenings. Documentation showed that the resident experienced multiple episodes of manic behavior, medication changes, and hospitalization, but no updated PASARR was completed by the facility.

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