Failure to Refer Residents for Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that residents with identified mental health diagnoses were properly referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. For one resident, the clinical record showed a diagnosis of Undifferentiated Schizophrenia with an onset date after the most recent PASRR Form 142 on file, which did not reflect the updated diagnosis. The staff member responsible for submitting resident review forms confirmed that a new review should have been submitted but was not. For another resident, the clinical record indicated diagnoses of Post-Traumatic Stress Disorder (PTSD) and Delusional Disorder upon admission. The staff member acknowledged that the Level I screening form failed to capture the Delusional Disorder diagnosis, which is considered a Tier 2 diagnosis and should have triggered a Level II review.