Failure to Complete PASARR Level II Evaluation for Resident With Bipolar Disorder
Penalty
Summary
The deficiency involves the facility’s failure to ensure completion of a PASARR Level II evaluation for a resident with a documented diagnosis of Bipolar Disorder. The resident was admitted with multiple diagnoses, including Bipolar Disorder and neurosyphilis, and had significant functional impairments, including dependence in most self-care activities, wheelchair use for mobility, and total incontinence of bowel and bladder. A quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact and able to participate in care planning, and documented mood symptoms such as little interest or pleasure in doing things, feeling down or depressed, and feeling tired or having little energy. The care plan specifically identified Bipolar Disorder as a focus, with a goal of mood stability and an intervention for staff to encourage treatment and medication compliance. Despite these findings and the documented diagnosis of Bipolar Disorder at admission, the PASARR Level I screening dated 04/14/2025 indicated a negative screen for intellectual disability or related conditions and stated no further action was necessary. However, ePASARR submissions dated 05/21/2025 and 03/11/2026 documented a positive screen for serious mental illness and were submitted to the Department of Health Care Facilities, indicating a possible need for further evaluation. There was no evidence in the medical record that a PASARR Level II evaluation was ever completed. During interviews, the Social Services Director stated he does not complete PASARR screenings and believed the psychiatric company’s evaluation completed the PASARR process, while the Business Office Manager described a process in which a psychiatric doctor evaluates new admissions and, if a mental illness is identified, an ePASARR is filed and the outside company determines the need for Level II. The resident was observed on multiple occasions lying in bed, expressing boredom and unhappiness about being in the facility, and often expressing anger about life, but no corresponding PASARR Level II evaluation was documented.
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