Failure to Update PASARR with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) documentation when new mental health diagnoses were identified for two of eight residents reviewed during the annual survey. For one resident, the electronic health record (EHR) listed diagnoses of anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD), but the most recent PASARR did not reflect any of these conditions. The PASARR form had options to indicate major depression, PTSD, and anxiety, but none were selected. Additionally, the Medical Diagnostic Screening (MDS) assessment for this resident marked PTSD but did not include anxiety disorder or depression, resulting in inconsistencies between the EHR, MDS, and PASARR documentation. The Director of Nursing (DON) confirmed that the EHR diagnoses were accurate and that the MDS and PASARR were not coordinated with the EHR. For another resident, a diagnosis of PTSD was present in the resident's diagnosis list but was not included on the PASARR. Both the DON and the Social Worker confirmed that the PTSD diagnosis was missing from the PASARR. These findings were based on record reviews and staff interviews, demonstrating a lack of coordination and updating of PASARR documentation when new mental health diagnoses were identified.