Failure to Refer Resident for PASRR Level II Review After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to refer a resident with newly identified serious mental disorders for a required Level II PASRR (Preadmission Screening and Resident Review) evaluation following a significant change in condition. Specifically, a female resident with a primary diagnosis of senile degeneration of the brain was admitted and initially screened negative for mental illness on her Level I PASRR. However, subsequent diagnoses of psychotic disorder with delusions and major depressive disorder were added to her record. Despite these new diagnoses, no new Level I PASRR was completed, and the resident was not referred for a Level II review as required. Interviews with facility staff revealed that the MDS coordinator, who was responsible for PASRR, was unaware of the need to complete a new Level I PASRR when new psychiatric diagnoses were made. The DON confirmed oversight responsibility but did not ensure the process was followed. The administrator acknowledged that failure to complete appropriate PASRR evaluations could result in residents not receiving necessary services. Additionally, the facility was unable to provide a PASRR policy when requested.