Failure to Complete PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to identify and act upon a diagnosis of mental illness for a resident during the preadmission screening and resident review (PASRR) process. Despite the resident having documented diagnoses of schizoaffective disorder, bipolar type, and borderline intellectual functioning, the Level I PASRR screening incorrectly indicated that the resident did not have a primary diagnosis of mental illness, intellectual disability, or developmental disability. The resident's medical records, including the face sheet, MDS assessment, care plan, and physician orders, all reflected active mental health diagnoses and the use of antipsychotic medication for schizoaffective disorder, bipolar type. Interviews with facility staff revealed that a Level II PASRR evaluation was not completed for the resident, even though the Level I screening should have triggered further assessment due to the mental illness diagnoses. The DON and ADON/MDS coordinator acknowledged the oversight, noting that PASRR services were not provided and that therapy services received by the resident were not through PASRR. Facility policy requires all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders, and mandates referral for Level II evaluation when indicated, but this process was not followed in this case.