Failure to Refer Resident for PASARR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a PASARR (Preadmission Screening and Resident Review) Level II comprehensive evaluation after the resident was diagnosed with Major Depressive Disorder and undifferentiated Schizophrenia following admission. The resident's records showed no diagnosis of dementia, but did indicate severe cognitive impairment, ongoing use of psychotropic medications, and receipt of psychological and psychiatric services. Despite these factors and the new diagnoses, the resident's PASARR Level I screening from a previous date indicated no mental illness, and no subsequent referral for a Level II evaluation was made after the new diagnoses were established. Interviews and record reviews revealed that the responsibility for PASARR referrals typically fell to the MDS Coordinator, a position that was vacant at the time. The DON confirmed that the resident should have been referred for PASARR services following the new diagnoses but was not. Additionally, the facility was unable to provide a PASARR policy when requested during the survey.