Failure to Complete Accurate PASARR Assessment for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASARR) Level I screening for a resident when the initial PASARR, completed prior to admission in a general acute care hospital, did not include the resident's diagnosis of anxiety or the use of psychotropic medications. Upon admission, the resident's records indicated diagnoses of anxiety, dementia, and Alzheimer's disease, and the resident was prescribed medications such as lorazepam and quetiapine fumarate. Despite these findings, the PASARR Level I assessment was not updated or reviewed for accuracy by the Admission Coordinator/Minimum Data Set Nurse (AC/MDSN), who acknowledged responsibility for ensuring accurate PASARR assessments for new admissions. Interviews with facility staff, including the AC/MDSN and the Director of Nursing (DON), confirmed that the PASARR assessment was not reviewed for accuracy upon admission, and a new assessment was not completed despite discrepancies in the resident's diagnoses and medication use. Facility policy requires a PASARR Level I screening for each resident upon admission and mandates review for accuracy, especially when there are significant changes in a resident's physical or mental condition. The failure to complete an accurate PASARR assessment had the potential to impact the resident's receipt of appropriate services related to their mental health diagnosis and medication regimen.