Failure to Complete Timely PASARR Level I for New Mental Health Diagnosis and Psychotropic Medication
Penalty
Summary
The facility failed to ensure a timely PASARR (Preadmission Screening and Resident Review) Level I screen was completed when a resident had a new mental health diagnosis and was prescribed a new psychotropic medication. The clinical record for Resident 4 showed multiple diagnoses including depression, atrial fibrillation, heart disease, vascular dementia, pseudobulbar affect, post-traumatic stress disorder (PTSD), and adjustment disorder with anxiety. A physician’s order dated 9/19/25 directed administration of diazepam 2 mg twice daily for anxiety, but a PASARR Level I screen related to the new anxiety disorder diagnosis and the new antianxiety medication was not completed until 2/2/26, after the survey had begun. During interview, the Administrator stated that when a resident has a new psychotropic medication or a new mental health diagnosis added, a new Level I PASARR is required, confirming that this was not done until 2/2/26 for this resident. The facility’s PASARR Quick Sheet policy indicated that when an individual has a severe mental illness/behavioral health diagnosis such as major depressive disorder or anxiety disorder, and the diagnosis is given by a psychiatric provider, the PASARR office should be contacted, but this process was not followed in a timely manner for Resident 4’s new anxiety diagnosis and diazepam order.
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