Failure to Complete Required PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
Facility staff failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) was completed for two residents with significant mental health diagnoses. One resident had diagnoses including cerebral infarction, metabolic encephalopathy, convulsions, unspecified psychosis, major depressive disorder, and generalized anxiety disorder, and was assessed as moderately cognitively impaired with delusions and wandering behavior. Despite residing in the facility for approximately five months, no Level I PASARR was found in the clinical record, and staff interviews confirmed that the screening had not been completed. The facility policy required all applicants to be screened for serious mental disorders or intellectual disabilities prior to admission, and for records of the pre-screening to be maintained in the resident's medical record. However, staff were unclear about their responsibilities regarding PASARR completion, with the social worker and admissions coordinator both stating they had not been instructed to complete the screenings. A second resident with diagnoses including suicidal ideations, major depressive disorder, and bipolar disorder with psychotic features also did not have a Level I PASARR in their clinical record. The resident was cognitively intact according to the most recent assessment. Staff interviews revealed a lack of awareness and training regarding the facility's policy on PASARR responsibilities, with both the social worker and admissions director stating they had never completed or been told to complete Level I PASARRs. The facility's policy designated the social services director as responsible for tracking PASARR status, but the social worker was unaware of this policy. No further information or documentation regarding PASARR completion was provided to the survey team prior to the exit conference.