Failure to Accurately Document Mental Health Diagnosis on PASARR Form
Penalty
Summary
The facility failed to ensure accurate documentation of a mental health diagnosis on the PASARR form for one resident who was reviewed for the need of a Level II screening. Specifically, the PASARR Level I form for the resident did not include the diagnosis of delusional disorder, despite this diagnosis being present in both the electronic medical record as an admitting diagnosis and in the resident's care plan. The PASARR form marked 'No' for the presence of a serious mental illness, and the State office was not notified as required. Interviews with facility staff revealed confusion regarding the nature of the resident's mental health diagnosis. The administrator acknowledged that delusional disorder was a mental health disorder relevant to PASARR, while the DON initially attributed the diagnosis to a metabolic condition but later confirmed it was a psychotic disorder. The DON stated that the PASARR was marked correctly at the time, but also confirmed that the State office was not contacted about the PASARR for this resident.