Failure to Request Level II PASRR After New PTSD Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to request a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a resident received a new mental health diagnosis. The resident was admitted with a completed Level I PASRR that specifically recommended resubmitting paperwork for a Level II PASRR if a new mental health diagnosis was suspected or if there was a significant change in condition. On review of the electronic medical record, the resident was diagnosed with post-traumatic stress disorder (PTSD) on 09/30/2025, but there was no documentation that a Level II PASRR evaluation request was submitted following this new diagnosis. The psychiatrist reported that at admission the resident had no known history of PTSD, but later began experiencing panic attacks, and a family member raised the possibility that past sexual trauma could be related. The psychiatrist then entered the PTSD diagnosis into the EMR, adjusted the resident’s medications, and changed the care assignment to remove male caregivers. The social worker, who was responsible for completing PASRR paperwork, acknowledged being aware of the PTSD diagnosis, receiving this information during morning clinical meetings, and knowing that a Level II PASRR request was required for new mental health diagnoses such as PTSD, but stated she did not submit the request and was unsure how she missed it. The administrator also stated an understanding that Level II PASRR should be completed in a timely manner upon admission, readmission, or when there is a change of condition or new mental health diagnosis.
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