Failure to Complete PASRR Reassessment for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder for a Level II PASRR review upon a significant change in status assessment. Specifically, a female resident with diagnoses of bipolar disorder and post-traumatic stress disorder (PTSD) was not reassessed with a new PASRR Level I screening, despite these qualifying diagnoses being documented after her initial admission. The original PASRR Level I assessment, completed prior to admission, indicated the resident was negative for mental illness, but subsequent records, including the MDS and care plan, reflected the presence of bipolar disorder and PTSD. Interviews with facility staff revealed a lack of understanding regarding the need for a new PASRR Level I assessment when a qualifying diagnosis is identified after admission. The DON, responsible for PASRR assessments, believed that a new screening was unnecessary if the diagnosis was presumed to be present prior to admission. The facility's policy on admission criteria did not address the need for re-screening based on new or newly identified qualifying diagnoses.