Failure to Refer for Level II PASRR Evaluation After Change in Mental Health Status
Penalty
Summary
The facility failed to refer a resident, who initially had a negative Level I Preadmission Screening and Resident Review (PASRR) result, for a Level II PASRR evaluation after new or possible serious mental disorder, intellectual disability, or other related conditions became evident. Clinical record review showed that the resident had diagnoses including anxiety disorder, hallucinations, and dementia with Parkinsonism, and was prescribed medications such as Depakote, Remeron, and Seroquel for behavioral and mental health conditions. The resident also received behavioral health services, as documented in visit notes. Despite these changes in diagnosis, medication, and behavioral health interventions, the facility did not update or submit a new PASRR referral as required. During staff interview, the DON acknowledged the expectation to update PASRR with such changes and reported the absence of a facility policy related to PASRR.