Failure to Update PASRR Evaluation for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident with multiple mental health diagnoses and psychotropic medications. Upon review, the resident's clinical record showed diagnoses including delusional disorders, non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, and a history of substance abuse. The resident was also prescribed antipsychotic, antianxiety, and antidepressant medications, among others. Despite these significant mental health conditions and medication changes, the PASRR on file, dated at the time of admission, indicated no mental health diagnoses, symptoms, or related medications. The care plan for the resident was updated several times to reflect ongoing mental health concerns, behavioral symptoms, and the use of psychotropic medications. However, the PASRR was not updated to reflect these changes, as required by facility policy and federal regulations. Staff interviews confirmed that the PASRR in the electronic health record was the only one available and that no new PASRR had been submitted, even after the resident's diagnoses and medication regimen changed. Administration acknowledged that the PASRR should have been resubmitted when the care plan was updated to include new diagnoses and medications. Facility policy requires prompt referral for a Level II PASRR review when a resident exhibits new or possible serious mental disorders or when new information arises that refutes the original PASRR findings. In this case, despite clear evidence of new and ongoing mental health diagnoses and the use of psychotropic medications, the facility did not coordinate with the PASRR program to ensure an updated evaluation was completed, resulting in a failure to comply with regulatory requirements.