Failure to Complete Accurate PASRR for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a diagnosed mental disorder, specifically post-traumatic stress disorder (PTSD), had an accurate Preadmission Screening and Resident Review (PASRR) completed. The resident, who had a history of alcohol abuse, major depressive disorder, anxiety disorder, PTSD, depression, adjustment disorder, and hallucinations, was admitted with a Level 1 PASRR that incorrectly indicated no evidence of mental illness. The care plan identified risks related to altered thought processes, and the resident's medical record documented multiple mental health diagnoses. Despite these documented conditions, the PASRR screening did not reflect the presence of a mental disorder, and the resident was not evaluated for specialized mental health care needs as required. During interviews, the resident reported not receiving any services for PTSD since admission and was unaware of any such offerings. The social services designee acknowledged that the PASRR was completed incorrectly and agreed that a Level II PASRR would have been appropriate. The facility's policy requires accurate identification and evaluation of residents with serious mental illness or intellectual disabilities, but this process was not followed, resulting in the failure to identify and address the resident's mental health care needs.