Failure to Accurately Complete PASRR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately. The resident was admitted with diagnoses including metabolic encephalopathy, rhabdomyolysis, post-traumatic stress disorder (PTSD), and anxiety. Upon review, the resident's PASRR Level 1 screening was marked as negative, indicating no serious mental illness, and therefore a Level 2 screening was not conducted. However, the resident had documented mental health diagnoses and was prescribed psychotropic medications for depression and anxiety, which were not reflected in the PASRR screening. Further review revealed that the PASRR Level 1 screening did not acknowledge the resident's mental health conditions, as question nine regarding serious diagnosed mental disorders was incorrectly answered "NO." The Director of Nursing confirmed that this should have triggered a Level 2 screening and that a status change review should have been completed when new psychotropic medications were started. The facility's policy requires the MDS Coordinator to ensure PASRR updates are completed according to guidelines, including after significant changes in status, which was not followed in this case.