Failure to Refer Resident with Bipolar Disorder for Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a diagnosis of bipolar disorder for a Level II PASRR evaluation upon admission and following a significant change in status assessment. The resident, an elderly female with multiple diagnoses including chronic kidney disease, Parkinson's disease, bipolar disorder, anxiety disorder, major depressive disorder, dysphagia, dementia, hypertension, and heart failure, was admitted and re-admitted to the facility with these conditions documented in her records. Despite the presence of a qualifying mental health diagnosis, the PASRR Level 1 screening completed by the referring entity did not indicate a mental illness, and no corrected Level 1 or Level 2 PASRR evaluation was completed for the resident. Review of the resident's comprehensive MDS assessment showed that the section for serious mental illness was left blank, even though the diagnosis of bipolar disorder was present in the medical record and care plan. The resident's BIMS score indicated moderate cognitive impairment, and the care plan included a focus on mood problems related to bipolar disorder and impaired cognitive function. However, the PASRR documentation failed to reflect the resident's mental health status accurately, and the necessary referral for a Level II evaluation was not made. Interviews with facility staff revealed that the MDS Nurse, who was responsible for PASRR screenings, was unaware that the initial Level 1 screening was incorrect and did not initiate a Level II evaluation as required. The Administrator and DON both acknowledged that accurate identification and coding of PASRR status is essential for ensuring residents receive appropriate services, and that the nursing team is responsible for this process. Facility policy requires review and submission of PASRR forms prior to admission, but this process was not followed in this case, resulting in the deficiency.