Failure to Reassess for PASRR After New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was reassessed for the Pre-Admission Screening and Resident Review (PASRR) following significant changes in mental health diagnoses and the initiation of new psychotropic medications. Specifically, the resident was admitted with multiple diagnoses, including hemiplegia, type II diabetes, unspecified anxiety disorder, unspecified persistent mood disorder, and chronic systolic heart failure. The medical record showed that the resident received new diagnoses of unspecified anxiety disorder and persistent mood (affective) disorder, and was prescribed several psychotropic medications, including Divalproex sodium, Ativan, and Lexapro, on multiple occasions. Despite these significant changes, there was no evidence in the medical record that a significant change PASRR assessment was completed after the new diagnoses or after the psychotropic medications were ordered. During an interview, the social worker confirmed that she had not reassessed the resident for PASRR because she was unaware of the changes in diagnoses and medications. Facility policy required the social worker to coordinate PASRR assessments and notify appropriate services if Level II services were needed, but this process was not followed in this case.