Failure to Complete Required PASRR Assessments for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) assessments were properly reviewed, completed, and submitted for two residents with mental health diagnoses. For one resident admitted with anxiety and depression and identified as moderately cognitively impaired, the PASRR indicated a Mood Disorder and noted an exempted hospital discharge, stating that a Level II evaluation was required if the resident remained beyond 30 days. However, no further PASRR was completed or transmitted after the resident stayed past the 30-day period. The Social Service Director acknowledged during interview that the review was missed and should have been completed. Similarly, another resident admitted with major depressive disorder was documented as alert and oriented, and their PASRR Level 1 assessment also indicated an Exempted Hospital Discharge with the requirement for a Level II evaluation if the stay exceeded 30 days. Record review showed no evidence that a new PASRR Level 1 or Level II was completed after the resident remained in the facility beyond the anticipated discharge period. The Social Service Director confirmed responsibility for PASRR referrals and admitted not submitting the required referral for a Level II evaluation, having not realized the resident's stay had exceeded 30 days.