Failure to Complete Accurate PASRR Screening and Referral for Mental Illness
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) evaluation was properly completed for a newly admitted resident prior to or after admission. Specifically, the PASRR Level 1 screening for the resident did not accurately reflect the resident's diagnoses of mental illness, including major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD). There was no evidence that the resident was referred for a Level 2 PASRR screening and evaluation, despite documentation of multiple mental health diagnoses in the medical record and care plans. The resident in question was an older male with a history of stroke, alcohol abuse, kidney failure, major depressive disorder, anxiety disorder, PTSD, mood disorder, dementia, insomnia, altered mental status, and agitation. The resident exhibited severe cognitive impairment, behavioral symptoms, and required extensive assistance with activities of daily living. He was also prescribed antianxiety, antidepressant, and hypnotic medications, and was receiving hospice care. Despite these significant mental health and behavioral concerns, the initial PASRR Level 1 screening from the hospital was negative for mental illness, intellectual disability, and developmental disability, and no subsequent screenings were completed. Further review of the resident's care plan and psychiatric assessments confirmed ongoing diagnoses of mood and anxiety disorders, as well as PTSD. The facility's MDS nurse acknowledged that the PASRR process was not followed correctly, including misreading instructions on the required forms and failing to submit a new positive Level 1 screening when indicated. Additionally, the facility administrator confirmed that there was no policy in place for PASRR at the time of the review.