Failure to Refer Residents for Level II PASRR Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents, who were initially screened as negative for serious mental disorder, intellectual disability, or related conditions through the Level I Pre-admission Screening and Resident Review (PASRR), for a Level II PASRR evaluation after new or possible mental health diagnoses became evident. For one resident, the Minimum Data Set (MDS) indicated the use of multiple high-risk psychotropic medications and documented diagnoses including psychological insomnia, major depressive disorder, schizotypical disorder, and anxiety disorder. Despite these findings, there was no evidence in the electronic health record (EHR) of a Level II PASRR evaluation since admission, which was confirmed by the Director of Nursing (DON). Another resident's MDS showed intact cognition but included diagnoses of progressive neurological conditions, anxiety disorder, depression, psychotic disorder, and non-Alzheimer's dementia. The initial PASRR Level I screen did not identify active psychosis or hallucinations, but subsequent EHR documentation revealed new diagnoses of major depressive disorder, unspecified psychosis, and visual hallucinations. Staff interviews confirmed that a new PASRR should have been completed following these new diagnoses, in accordance with facility policy, but this was not done.