Failure to Complete Accurate PASRR Level I Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that all residents with mental illness diagnoses received accurate Pre-admission Screening and Resident Review (PASRR) Level I assessments, resulting in two residents not being properly identified for further PASRR Level II evaluation. Both residents had documented diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD), with one also having dementia. Despite these diagnoses, their PASRR Level I forms incorrectly indicated that they did not have a mental illness. For one resident, medical records showed active diagnoses of depression and PTSD, moderate cognitive impairment, and ongoing treatment with Sertraline for depression. The care plan included interventions for mood problems related to depression, dementia, and PTSD. However, the PASRR Level I form for this resident was marked as negative for mental illness, and no PASRR Level II evaluation was conducted. The second resident also had active diagnoses of major depressive disorder and PTSD, was cognitively intact, and was prescribed Buspirone for anxiety. The care plan included referrals to mental health authorities and therapy. Despite these documented mental health conditions, the PASRR Level I form was marked negative for mental illness, and no PASRR Level II evaluation was completed. Interviews with facility staff confirmed the inaccuracies in the PASRR Level I assessments and the absence of a PASRR policy at the facility.