Failure to Update PASRR for Resident With Additional Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) for a resident who was admitted with additional mental health diagnoses not reflected on the original PASRR. Facility policy stated that the PASRR process applies to all admissions, particularly for individuals with serious mental illness, intellectual disability, or related conditions, and that a resident review is to be conducted when there is a change in the resident's condition that may trigger a new PASRR evaluation. The resident’s Level I PASRR screen, completed prior to admission, documented an anxiety disorder and use of Buspar 10 mg daily, but did not include diagnoses of PTSD or schizoaffective disorder. The medical record showed that upon admission the resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, schizoaffective disorder, anxiety disorder, and PTSD. A subsequent quarterly MDS assessment documented severe cognitive impairment with a BIMS score of 5 and active diagnoses of anxiety disorder, schizophrenia, and PTSD. The comprehensive care plan further identified antidepressant use related to depression and schizoaffective disorder, antipsychotic use related to schizophrenia, risk for re-traumatization related to PTSD, and potential mood problems related to depression, anxiety, and schizoaffective disorder. During interviews, the Admissions/LPN Nurse Case Manager and the DON confirmed that a new PASRR to include PTSD and schizoaffective disorder was not submitted after the resident’s admission.
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