Failure to Complete PASARR After Significant Change in Mental Condition
Penalty
Summary
The facility failed to ensure the completion and accuracy of a Level I Preadmission Screening and Resident Review (PASARR) following the readmission of a resident with a diagnosis of Serious Mental Illness (SMI) after a significant change in her mental condition. The resident, who had a history of multiple sclerosis, major depressive disorder, anxiety, and seizures, was readmitted from an acute care hospital and subsequently developed additional psychiatric diagnoses, including bipolar disorder, brief psychotic disorder, and psychosis. Despite these new diagnoses and significant behavioral changes, there was no evidence that a new Level I PASARR was completed after her readmission or following the onset of new psychiatric symptoms. The resident exhibited a range of severe behavioral symptoms, including hallucinations, delusions, impulsivity, aggression, resisting care, and socially inappropriate behaviors. Progress notes documented multiple incidents where the resident called 911, refused medications, food, and drink, and required emergency interventions such as the administration of psychotropic medications and involuntary psychiatric holds under state law. The medical record also showed ongoing psychiatric evaluations and medication adjustments due to persistent psychosis, agitation, and mood instability. Despite these significant changes, the PASARR documentation in the record was incomplete, with key sections left blank and no indication that a Level II evaluation was considered or initiated. Interviews with facility staff, including the LPN, Social Services Assistant, DON, and Administrator, confirmed that the PASARR was not reviewed or resubmitted after the resident's significant behavioral changes and new psychiatric diagnoses. The DON acknowledged that a new PASARR should have been completed in such circumstances, and the Administrator admitted the omission was an oversight. Additionally, the facility lacked a policy defining which staff member was responsible for updating PASARRs, and no behavioral health or behavior management policy was provided upon request.