F0644

E

Failure to Resubmit and Update PASRR for Residents With Mental Illness and Psychiatric Hospitalizations

Greensburg, Louisiana Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure required Preadmission Screening and Resident Review (PASRR) Level II evaluations and resubmissions for residents with identified or newly diagnosed mental illness, and for residents experiencing significant changes such as psychiatric hospitalization. For one resident, the clinical record showed admission with diagnoses including traumatic subdural hemorrhage, anxiety disorder, irritability and anger, and major depressive disorder. The resident’s PASRR Level I form, dated prior to admission, did not list any mental health diagnoses, despite the medical record and MAR documenting treatment with Seroquel and Sertraline for major depressive disorder, with the diagnosis onset and medication start dates clearly recorded. The DON confirmed that the admitting diagnoses included major depressive disorder, and care plan and IOP assessments documented depression, anxiety, hallucinations, delusions, withdrawal, and mood swings.

Further review showed that this same resident’s PASRR Level I (142 form) approval date was more than 30 days before the actual admission date, and the resident had been discharged from the facility for more than 30 days before returning, which staff acknowledged should have triggered a new PASRR. Interviews with the social worker, MDS staff, and DON confirmed that no new PASRR was completed upon the resident’s return, despite the extended absence and subsequent significant changes, including a PEC (Physician’s Emergency Certificate) event and increased psychotropic medications. The DON and administrator also verified that they were not aware that a Resident Review form and PASRR review were required after such significant changes or the addition of IOP services.

For another resident, the clinical record showed admission without psychiatric diagnoses initially, but later documentation reflected a diagnosis of major depressive disorder. The resident’s original Level I PASRR, completed by a local hospital, did not list any mental illness in the mental illness section. The social worker confirmed that there was no process to identify residents with new mental illness diagnoses who required a resubmitted Level I PASRR for possible Level II evaluation and stated she was unaware that resubmission was required after a new psychiatric diagnosis. This resident also had an unplanned discharge to an inpatient psychiatric facility under a PEC for escalating agitation and threatening behaviors, with documentation of severe major depressive disorder and increased Abilify for uncontrolled symptoms. Despite this inpatient psychiatric admission and diagnosis, there was no evidence of any subsequent Level I PASRR resubmission, and both the social worker and DON confirmed that the PASRR had not been updated and that there was no process in place to review PASRRs for accuracy when such events occurred.