Failure to Complete Required PASRR Level II Evaluations for Residents with Mental Health Indicators
Penalty
Summary
The facility failed to ensure that Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained for three residents who exhibited or developed indicators of serious mental illness or behavioral issues. According to facility policy, all new admissions and readmissions should be screened for mental, intellectual, or related disorders, and if a Level I PASRR indicates possible mental health needs, a referral for a Level II evaluation must be made. However, for three residents, this process was not followed as required. One resident with cognitive impairment and depression had documented behavioral issues, confusion, and hallucinations, but no Level II PASRR referral was made despite these indicators. Another resident with chronic medical conditions and a history of behavioral problems, including elopement attempts, aggression, and medication refusal, was not rescreened or referred for a Level II PASRR after significant changes in behavior. Staff interviews revealed a lack of awareness regarding the need to repeat the PASRR process following changes in condition. A third resident with impaired cognitive function and delusional thoughts, including recent psychotic disturbances, was also not rescreened or referred for a Level II PASRR after new symptoms emerged. Staff acknowledged uncertainty about the requirements for rescreening and the Level II PASRR process, and confirmed that screenings and referrals should have been completed for these residents but were not. This failure was identified through observation, interview, and record review, and was found to be inconsistent with both facility policy and regulatory requirements.