Failure to Refer Resident for Level II PASRR Evaluation After New Mental Health Diagnoses
Penalty
Summary
A deficiency occurred when the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after the resident was identified with new or possible serious mental disorders. The resident initially had a negative Level I PASRR result, with the screening only documenting diagnoses of major depression and anxiety disorder. However, subsequent clinical record reviews revealed new diagnoses of anorexia and unspecified psychosis, which were not included in the original PASRR documentation. The facility did not update or resubmit the PASRR referral upon receiving these new diagnoses. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for PASRR submissions at the time and acknowledged that the new diagnosis of psychosis should have triggered a new PASRR referral. The DON admitted to not considering anorexia as a qualifying diagnosis for PASRR resubmission and recognized the oversight. Additionally, the facility lacked a formal policy for PASRR submissions and relied on general requirements for status changes, contributing to the failure to refer the resident for appropriate evaluation.