Failure to Submit Level II PASRR Evaluation for Resident with New Serious Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was newly diagnosed with a serious mental illness. The resident was admitted with diagnoses of generalized anxiety disorder and unspecified depression, and a Level I PASRR was completed prior to admission. Subsequently, the resident was diagnosed with bipolar disorder by a psychiatrist, and new psychotropic medications were ordered and adjusted to address behaviors related to psychosis. Despite these changes, there was no evidence in the electronic medical record that a Level II PASRR screening was requested for the resident. Interviews with facility staff revealed gaps in communication and process oversight. The MDS nurse acknowledged noticing the new diagnosis and medication orders but did not recognize the need to notify the administrator for a Level II PASRR evaluation. The social worker did not have access to the state's PASRR submission system and indicated that the administrator was responsible for submitting requests. The DON believed the resident already had a Level II PASRR determination and maintained a list of residents needing screenings. The administrator confirmed she had not submitted a request for a Level II PASRR for this resident and relied on notifications from the DON and MDS nurse regarding changes in residents' conditions.