Failure to Accurately Complete PASARR Screening and Referral for Mental Illness
Penalty
Summary
The facility failed to ensure accurate completion of Pre-admission Screening and Resident Review (PASARR) Level I screenings and did not provide a required PASARR Level II assessment for a resident with a mental illness. Specifically, a 76-year-old resident admitted with a diagnosis of Post-Traumatic Stress Disorder (PTSD) was not properly identified as having a mental illness on the initial PASARR Level I screening completed by the hospital prior to admission. The facility's own PASARR Level I screening, completed on the day of admission, also failed to document the resident's mental illness, despite the diagnosis being present in the medical record and care plan. The MDS Coordinator (MDSC) acknowledged that the initial PASARR Level I screening was inaccurate and explained that a second screening was completed later the same day after the mental health diagnosis was discovered upon closer review of the resident's record. The MDSC admitted that a referral for a PASARR Level II assessment was not made due to a mistake by the facility. Interviews revealed that the MDSC was new to the role and was not fully familiar with the facility's process for identifying and referring residents with mental disorders, intellectual disabilities, or related conditions. Further interviews with the Interim Director of Nursing (DON) indicated a lack of clear understanding and consistent process for ensuring PASARR screenings are completed accurately and referrals are made when necessary. The facility's policy required PASARR screenings to be completed prior to admission and referrals for Level II assessments to be made when a mental health diagnosis is identified, but this was not followed in the case of the resident with PTSD.