Failure to Complete PASARR Prior to Admission for Residents with Mental Illness
Penalty
Summary
Facility staff failed to ensure that a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for two residents with significant mental health diagnoses. For one resident, who was admitted with schizophrenia, bipolar disorder, mood disorder, and anxiety disorder, the PASARR I was not completed until a year after admission and was incorrectly coded, failing to identify the resident's serious mental illness. Despite ongoing psychotropic medication use, psychiatric follow-up, and documented behavioral issues such as aggression and abuse, the PASARR II was never triggered or completed as required. All relevant deficits and behaviors were well documented in the clinical record at the time. For another resident admitted with bipolar disorder, metabolic encephalopathy, psychoactive substance abuse, and seizures, no PASARR was found to have been completed prior to admission. The only PASARR in the record was dated after admission and did not document the psychiatric diagnosis. Facility staff confirmed that no PASARR had been completed prior to admission, and the Director of Nursing acknowledged that the screening should have been done to document the listed diagnoses.