Failure to Update PASARR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASARR) Level II after the resident received a new diagnosis of a severe mental illness. The resident was originally admitted with no diagnosis of mental illness, as indicated by the initial PASARR Level I screening. However, subsequent documentation, including the resident's Face Sheet and Minimum Data Set (MDS), showed a diagnosis of bipolar disorder and severe cognitive impairment. The care plan also reflected the presence of bipolar disorder and the use of psychotropic medications. Despite these updates to the resident's medical condition, the facility did not update or resubmit the PASARR Level I to the state as required when a new diagnosis of mental illness is identified after admission. Interviews with facility staff, including the DON and Administrator, confirmed that the process for updating the PASARR was not followed for this resident after the new diagnosis was made.