Failure to Refer for Level II PASARR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR (Pre-admission Screening and Resident Review) after a new diagnosis of Delusional Disorder was added to the resident's medical record. The resident was originally admitted with diagnoses including unspecified dementia, moderate without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The initial Level I PASARR screen did not indicate suspicion or diagnosis of a mental illness. However, after the new diagnosis of Delusional Disorder was documented, there was no evidence in the medical record that a new PASARR was completed or submitted. This was confirmed during an interview with the corporate nurse, who acknowledged that a new PASARR should have been completed following the updated diagnosis.