Failure to Accurately Complete PASRR Screenings and Referrals
Penalty
Summary
The facility failed to properly review and validate the accuracy of Preadmission Screening and Resident Reviews (PASRR) for residents with mental disorders or intellectual disabilities. For three residents, the PASRR Level I screenings did not accurately reflect their mental health diagnoses, and required Level II referrals were not completed when indicated. Specifically, one resident was admitted with diagnoses of dementia, major depressive disorder (MDD), and anxiety, but their Level I PASRR did not document the MDD or anxiety, and no Level II referral was made. Another resident with depression had a Level I PASRR indicating a mood disorder, which should have triggered a Level II referral, but no such referral was found in the record. A third resident with depression, anxiety, and PTSD had a PASRR that did not document the PTSD diagnosis. Staff interviews revealed that the admissions and social services staff were responsible for reviewing PASRRs for accuracy but failed to identify or correct these omissions prior to or after admission. In some cases, staff relied on the hospital to provide accurate PASRRs and did not ensure corrections were made before residents were admitted. These failures resulted in incomplete PASRR documentation and the absence of required Level II referrals for residents with significant mental health diagnoses.