F0645

E

Failure to Accurately Complete PASRR Screenings and Level II Referrals for Multiple Residents With Mental Disorders

Tucson, Arizona Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate completion, updating, and referral of PASRR Level I screenings and Level II evaluations for multiple residents with serious mental illness (SMI) or other mental disorders. For one resident with borderline personality disorder, PTSD, recurrent depression, anxiety disorders, and factitious disorder, hospital-generated PASRRs repeatedly documented “no” history of SMI, mental disorders, or psychotropic medications, despite extensive behavioral health diagnoses and active psychotropic orders. The facility did not correct these PASRRs or complete a Level I PASRR after the 30‑day convalescent period ended, even though the resident’s MDS assessments, psychiatric notes, care plans, and social services assessments consistently documented anxiety, depression, PTSD, borderline personality disorder, and ongoing psychiatric treatment.

Another resident with PTSD, depression, generalized anxiety disorder, bipolar disorder, polysubstance abuse, and recent inpatient psychiatric hospitalization for suicidal ideation had a PASRR Level I that omitted major depression and bipolar disorder and incorrectly indicated no recent psychiatric hospitalization or suicidal ideation. A subsequent PASRR Level I, completed after re‑admission, documented bipolar disorder and anxiety disorder but again indicated no recent psychiatric hospitalization or suicidal ideation and concluded that no Level II referral was necessary. The clinical record showed no evidence of any PASRR Level II referral for this resident. A separate resident with diabetes, depression, and later‑added bipolar disorder exhibited altered mental status and psychotic‑like behavior, prompting a psychiatric consult. However, the quarterly MDS did not list bipolar disorder as an active diagnosis, and the PASRR Level I documented major and mild/situational depression but stated the resident did not have bipolar disorder and did not require a Level II referral, with no Level II referral found in the record.

For another resident admitted and re‑admitted with anxiety disorder, schizophrenia, recurrent depressive disorder, chronic PTSD, and polysubstance abuse in remission, multiple PASRR Level I tools were inconsistent with the clinical record. One hospital PASRR identified bipolar disorder and personality disorder and psychotropic use but did not document whether a Level II referral was needed. A subsequent facility PASRR Level I documented schizophrenia and anxiety disorder but stated the resident was not prescribed psychotropic medications, despite the admission MDS showing active anxiety, depression, schizophrenia, and use of antianxiety, antidepressant, antipsychotic, and anticonvulsant medications. A later PASRR Level I listed schizophrenia only, omitted depression, anxiety, and other mental disorders, and left the Level II referral determination section blank, even though the same form listed multiple psychotropic medications for depression, anxiety, and schizophrenia. No Level II referral was present in the record.

Additional residents with multiple psychiatric diagnoses and psychotropic treatment also lacked accurate PASRR documentation and appropriate Level II referrals. One resident with anxiety disorder, bipolar disorder (current episode depressed), and schizophrenia had a PASRR Level I that correctly listed these diagnoses and related psychotropic medications but indicated no Level II referral; a later PASRR for the same resident omitted all mental illness diagnoses and psychotropic medications, again indicating no Level II referral, despite MDS documentation of anxiety disorder, bipolar disorder, schizophrenia, and use of antipsychotics and antidepressants. Another resident with aphasia, anxiety disorder, recurrent depressive disorder, mood disorder, personality and behavioral disorder due to physiological condition, and adjustment disorder had an initial PASRR listing anxiety and depression with no Level II referral, followed by a second PASRR that omitted all diagnoses and psychotropic medications, again indicating no Level II referral, despite orders and care plans for Depakote and anticonvulsant therapy for mood disorder. In interviews, the Director of Social Services acknowledged that PASRRs were inaccurate or incomplete, that required Level II referrals had not been submitted for several residents, that the facility was responsible for ensuring PASRR accuracy, and that she was uncertain about PASRR update requirements and tracking for residents needing Level II evaluations.

The Director of Social Services further stated that the facility’s process for identifying residents with mental disorders or intellectual disabilities involved review of diagnoses such as depression, anxiety, bipolar disorder, and schizophrenia, and review of psychiatric medications, and that residents with more than one or two psychiatric diagnoses and stays longer than 30 days should automatically have a Level II PASRR referral submitted. She confirmed that she was responsible for completing Level I PASRRs and submitting Level II referrals, that PASRR resource reviews were infrequent and random, and that she had not received formal performance evaluation or sufficient training to identify knowledge gaps. She also stated that inaccurate or incomplete PASRR screening and referral processes could result in residents not receiving the services they need, and that accurate PASRR completion is critical to resident safety and quality of care.