Failure to Complete Required PASARR Level 2 Screening
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a required PASARR (Preadmission Screening and Resident Review) process was completed for a resident with a diagnosis of depression. The facility's policy requires that all admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders through the PASARR process. In this case, the Level 1 PASARR screen, which should have been completed prior to admission, was instead completed on the day of admission. The Level 1 screen indicated the presence of a major mental disorder and the use of psychotropic medications, which should have triggered a Level 2 PASARR evaluation. Despite the Level 1 screen results indicating the need for further assessment, there was no documentation of a Level 2 PASARR being completed for the resident. The surveyor confirmed with the Director of Nursing that the Level 2 screen had not been completed and that the Level 1 screen had only recently been sent to the agency responsible for Level 2 reviews. This oversight resulted in the resident not receiving the required Level 2 PASARR evaluation within the appropriate timeframe as outlined by facility policy.