A resident with depression and PTSD remained in the facility beyond the 30-day exemption period, and the required PASARR Level II screen was not completed. The Level I PASARR indicated a major mental disorder and psychotropic medication use, but the SW could not produce the Level II review and the NHA confirmed it had not been done.
PASARR screening was not completed for one resident on admission. The resident had mild cognitive impairment and generalized anxiety disorder, and the chart only contained a PASARR Level I Screen from a prior stay. When the surveyor requested the current PASARR, the NHA stated it had been missed; the facility later produced a PASARR showing serious mental illness and a 30-day hospital discharge exemption.
The facility did not complete Level II PASARR screenings for three residents after Level 1 screenings with 30-day exemptions, and one short-term resident had no Level II PASRR at all. The residents had diagnoses including dementia, PTSD, bipolar disorder, major depressive disorder, and anxiety, and staff confirmed the Level II screenings were not completed as expected.
A resident with PTSD, mood disorder, and psychotropic medication use remained in the facility far beyond a short-stay exemption period, but no PASRR Level II was completed after the resident became LTC. Surveyors observed the resident yelling and refusing care, and the DON acknowledged the Level II was not addressed once the resident stayed past the expected 30 days. An LPN stated Level 2 was needed if a resident stayed beyond 30 days but did not know how the facility tracked that requirement.
A resident with PTSD and orders for Seroquel had a PASRR Level I that identified a major mental disorder, but no PASRR Level II was found in the record. The SSD stated PTSD would trigger a PASRR II and acknowledged the screening was missed and not completed.
A resident admitted with major depressive disorder had a PASARR Level I screen indicating suspected serious mental illness, but the medical record did not include a PASARR Level II screen. The SW confirmed she was responsible for obtaining PASARR screenings and stated the resident should have had a Level II screen completed but did not.
PASARR screening was not completed appropriately for 3 residents reviewed. One resident with anxiety-related diagnoses had no Level II PASARR despite the facility’s Level I screen, another resident with major depressive disorder, anxiety, and depression had a positive Level I screen but no Level II documentation, and a third resident with schizophrenia and anxiety had no PASARR 1 or PASARR 2 completed even though the record showed a hospital discharge exemption.
A resident admitted with PTSD, anxiety, depression, personality disorder, and mood disorder did not have a required Level II PASARR completed after a Level I PASARR identified a major mental disorder and a 30-day exemption. The resident had intact cognition on BIMS and was observed ambulatory and independent with eating, toileting, and transfers. SS confirmed no follow-up PASARR II had been completed.
A resident with cerebral palsy, epilepsy, hydrocephalus, bipolar disorder, major depressive disorder, anxiety disorder, and severely impaired cognition had a PASARR Level 1 indicating a Level 2 was required, but the facility could not initially locate the Level 2 in the record. The NHA later provided a document identified as the Level 2, but it did not show when it was completed or submitted, and the facility could not determine the submission date.
PASRR screening was not accurately completed for a resident with schizoaffective disorder and anxiety disorder. The Level I screen did not reflect the resident’s mental health diagnoses or lorazepam order, and no Level II screen was submitted based on the incomplete information. Staff stated they did not initiate a Level II review because the resident was not on medication for schizoaffective disorder at admission, and later verified the omission and need for Level II review when lorazepam was ordered.
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