Failure to Refer Resident With Serious Mental Illness for Level II PASRR Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple serious mental health diagnoses was referred for a Level II Pre-admission Screening and Resident Review (PASRR) as required. The resident was initially admitted and later readmitted with diagnoses including myocardial infarction, depression, anxiety disorder, bipolar disorder, schizoaffective disorder, psychotic disorder with hallucinations, and schizophrenia. Care plans dated in early January 2024 documented the resident’s use of antipsychotic and antidepressant medications related to schizoaffective disorder and identified psychosocial well-being problems related to anxiety, depression, psychosis, substance abuse, schizoaffective disorder, and bipolar disorder, with an intervention to initiate referrals as needed. A Level I PASRR dated March 8, 2024 indicated that the resident did not have a Serious Mental Illness such as schizophrenia, schizoaffective disorder, bipolar disorder, major depression, or paranoid disorder, and listed only anxiety disorder and depression as mental disorders, concluding that no Level II referral was necessary. However, the resident’s clinical record and subsequent assessments documented active diagnoses of anxiety disorder, depression, bipolar disorder, psychotic disorder with hallucinations, schizoaffective disorder, and schizophrenia, and confirmed ongoing use of antipsychotic and antidepressant medications. An MDS assessment showed the resident was cognitively intact and had active psychiatric diagnoses, and provider progress notes in May and September 2025 continued to list multiple serious mental health conditions and active psychotic symptoms. Interviews with staff revealed gaps in the PASRR process and responsibilities. The case manager reported she was not trained in PASRR screening and did not perform it, stating that the resident relations manager handled PASRRs. The resident relations manager, a CNA, stated she completes PASRRs on admission, ensures hospital PASRRs are in place, and initiates Level II referrals when indicated, such as when residents exhibit behaviors or are prescribed psychiatric medications. She acknowledged that multiple Level I PASRRs for this resident were completed by the hospital and that a subsequent Level I PASRR was done after the resident remained more than 30 days, but none identified Serious Mental Illness despite the record showing schizoaffective disorder, bipolar disorder, and psychotic hallucinations. She confirmed that no Level II PASRR referral was made for this resident and could not explain why, and the administrator documented that the facility did not have a PASRR Level II referral for this resident, despite facility policy stating that a Level II referral must be submitted when a resident is positive for potential mental illness.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.