PASRR Not Updated for New Mental Health Diagnoses: A resident with existing mental health diagnoses later developed PTSD and Major Depressive Disorder, but the facility did not update the PASRR or submit it for Level II review. The PASRR had listed anxiety, depression, and auditory hallucinations, and staff confirmed it needed to be updated after the new diagnoses were identified.
PASARR and MDS diagnoses were not aligned for two residents. One resident had dementia with mood disturbance, major depressive disorder, and adjustment disorder, but the PASARR only listed behavioral disturbance and adjustment disorder while the MDS checked depression and dementia; the resident was also receiving escitalopram for depression. Another resident had major depressive disorder, dementia, epilepsy, and anxiety, but the PASARR marked only dementia under other related conditions while the MDS included depression and major depressive disorder. The NHA stated the Director of Admissions was responsible for keeping PASARRs up to date.
PASARR Not Updated After New PTSD Diagnosis: A resident’s PASARR was not updated after PTSD was added to the medical record. The PASARR had been completed when the resident transferred in, but it was not revised to reflect the new diagnosis. An RN confirmed the finding during interview.
Failure to complete required Level II PASARR review for a resident with a newly evident serious mental health disorder diagnosis. Survey review found the Level II had not been completed after the initial PASARR identified it was needed, and staff confirmed it was still pending until the evaluator was scheduled to come to the facility.
Failure to refer residents with newly evident mental disorders for PASARR review. Three residents had mental health diagnoses documented on the MDS, including depression, anxiety, bipolar disorder, PTSD, and mood disturbance, but their PASARRs did not reflect the full set of diagnoses or were marked with no current diagnoses. Record review and staff interview showed the NHA and DON acknowledged the discrepancies.
The facility failed to update PASARRs for two residents after new mental health diagnoses were documented. One resident had MDD, anxiety, and bipolar disorder added to the record, and another resident had PTSD noted on the MDS, but the EMR showed no evidence of updated PASARRs. The admission coordinator stated updated PASARRs had been resubmitted but could not provide proof.
The facility failed to coordinate MDS diagnoses with PASARR findings for two residents. One resident had major depressive disorder and vascular dementia, but the PASARR marked no major mental illness; another resident had epilepsy, anxiety, major depressive disorder, and later bipolar disorder, while the PASARR did not reflect any mental illnesses even though the MDS marked seizure disorder, anxiety disorder, and bipolar disorder.
A resident with a diagnosis of Psychoactive Substance Abuse had a PASARR that did not identify that diagnosis. Record review showed the diagnosis in the chart, and the Social Worker agreed it should have been included on the PASARR.
A resident with Bipolar II Disorder added after admission did not have an updated PASRR reflecting the diagnosis. The most recent PASRR did not list or check Bipolar Disorder in Section 30, and the DON confirmed the omission during record review.
Incorrect or incomplete PASARRs were found for three residents after new mental health diagnoses were identified or current diagnoses were not reflected on the PASARR. One resident had dementia listed as the primary diagnosis but also had bipolar disorder, hallucinations, and a provider attestation indicating schizoaffective symptoms; another resident’s PASARR listed bipolar disorder while later records showed depression and related psychotropic orders; a third resident’s PASARR omitted PTSD despite an active PTSD diagnosis.
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