Failure to Update PASRR Documentation After New Mental Health Diagnosis
Penalty
Summary
A deficiency was identified when the facility failed to update the PASRR (Pre-admission Screening and Resident Review) Level I form for a resident who had a new diagnosis of delusional disorder during their stay. The facility's policy requires that any new diagnosis identified during a resident's stay be added to the Level I PASRR form. However, review of the clinical record showed that the resident was admitted with schizoaffective disorder and later diagnosed with delusional disorder, but the PASRR Level I form, initially completed at admission, was not updated to reflect the new diagnosis. Staff interviews confirmed that there was no evidence of the PASRR Level I form being updated after the new diagnosis was made. This failure to update the PASRR documentation was found during clinical record review and staff interviews, and it was determined that the facility did not coordinate assessments with the PASRR program as required by policy and regulation.