Failure to Update PASARR Assessments After Significant Psychosocial Changes
Penalty
Summary
The facility failed to ensure that Level II Preadmission Screening and Resident Review (PASARR) evaluations were requested for two residents following significant changes in their psychosocial conditions that required emergency mental health interventions. For one resident with diagnoses including Anxiety Disorder, Depression, and PTSD, the initial Level I PASARR screen was negative, and no Level II evaluation was deemed necessary at admission. However, the resident later exhibited suicidal ideation on two separate occasions, resulting in transfers to the emergency department for further evaluation. Despite these significant changes, the facility did not update or resubmit the Level I PASARR for an additional review and Level II evaluation. Another resident, admitted with Major Depressive Disorder, Anxiety, and Depression, had a Level I PASARR indicating a history of mood and anxiety disorders, and a Level II determination that no further PASARR involvement was required. This resident subsequently made multiple statements about suicidal ideation, leading to hospital admissions for evaluation and observation. The facility did not report these changes in status to the PASARR office, as confirmed by the social worker. The failure to coordinate updated PASARR assessments following these acute psychosocial events constituted the deficiency.