Failure to Complete PASARR Level II Evaluation After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident who received a new diagnosis of schizophrenia was referred for a required Preadmission Screening and Resident Review (PASARR) Level II evaluation. The resident was admitted in 2010 and was diagnosed with schizophrenia in 2018. Despite this new diagnosis, there was no documented evidence in the clinical or medical record that a Level II PASARR evaluation was completed following the diagnosis. The resident's annual assessment indicated severe cognitive impairment and an active diagnosis of schizophrenia without dementia, and a care plan was developed for behavioral alterations related to psychosis, including placement on the Memory Care Unit. During an interview, the Social Service Director confirmed that the required Level II PASARR evaluation had not been completed after the new diagnosis.