Failure to Refer Resident for PASRR Level II Evaluation
Penalty
No penalty information released
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 refer a resident with diagnosed mental disorders, including PTSD and anxiety, to the appropriate state-designated authority for a PASRR Level II evaluation. Upon admission, the resident's PASRR Level I screening inaccurately documented that the resident did not have any mental illnesses, despite medical records indicating otherwise. The admission MDS assessment also reflected that the resident did not have a major mental illness, and no further PASRR evaluations were found in the medical record. Staff confirmed that the PASRR Level I was inaccurate and should have been updated at the time of admission, and acknowledged that a PASRR Level II evaluation should have been completed.