Deficient PASARR Screening and Documentation for Residents with Mental Health Needs
Penalty
Summary
The facility failed to ensure proper completion and documentation of the Preadmission Screening and Resident Review (PASARR) process for two residents. For one resident, the Level I PASARR was marked as 'No level II evaluation indicated at this time due to exempted hospital discharge,' with a note that a Level II must be completed if discharge does not occur. Despite the resident remaining in the facility for more than 30 days, no new Level I PASARR was completed as required. Staff interviews confirmed that a new Level I PASARR should have been completed after the 30-day stay, but it was not found in the resident's electronic health record. For another resident, a Level I PASARR identified a diagnosis of mood disorders and a recent decline in mood, indicating the need for a Level II PASARR referral. Although staff stated that a referral was made, there was no documentation in the electronic health record to confirm that the referral was sent. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders, and that referrals for Level II evaluations be made when indicated by the Level I screen. The lack of documentation and failure to complete required screenings resulted in deficiencies in the PASARR process for both residents.