Failure to Refer Resident for Level II PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR (Preadmission Screening and Resident Review) following a new diagnosis of Major Depressive Disorder. Record review showed that the resident was admitted with no prior diagnosis of mental disorder, intellectual disability, or related condition, as indicated by a negative Level I PASARR screening. However, subsequent documentation, including the resident's face sheet, MDS record, and care plan, confirmed a diagnosis of Major Depressive Disorder. Despite this significant change in condition, there was no evidence that the resident was referred for a Level II PASARR evaluation, nor was the resident listed among PASARR-positive residents. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, confirmed that the facility's policy requires a new PASARR screening upon a significant change in condition or new diagnosis of mental illness, intellectual disability, or related condition. Staff acknowledged that failure to conduct an accurate PASARR screening could result in residents not receiving appropriate services. The MDS Coordinator was identified as responsible for PASARR screenings, but the required referral for Level II PASARR was not completed for the resident after the new diagnosis.