A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
A resident with schizoaffective disorder, bipolar disorder, anxiety, severe cognitive impairment, and behavior issues had a PASRR Level 1 that did not reflect her mental health diagnoses. The DON, Regional MDS Nurse, and ADM stated that a new PASRR review should be completed when a new MI diagnosis is identified, but the facility did not complete a new PL1 when the resident’s diagnoses were documented.
The facility failed to ensure accurate PASRR Level I screenings and appropriate PASRR referrals for two residents with documented mental illness diagnoses. One resident’s records showed schizoaffective disorder, depression, generalized anxiety disorder, and schizophrenia, yet the PASRR Level I from the referring hospital indicated no mental illness. Another resident had depression, vascular dementia with psychotic disturbance and anxiety, and later a new diagnosis of schizophrenia, but her PASRR Level I also showed no mental illness and she was not referred for a PASRR Level II after the new schizophrenia diagnosis. The MDS Coordinator acknowledged that the PASRR for one resident should have been positive and corrected, and that she was unaware of the other resident’s new schizophrenia diagnosis and had not notified the local authority, while the DON and Administrator confirmed the MDS Coordinator’s responsibility for PASRR accuracy and follow‑through.
PASARR services were not properly coordinated or documented for one resident with schizophrenia, anxiety, and bipolar disorder. The PASARR care plan called for group therapy, individual therapy, and routine case management, but the chart lacked documentation of those services, and staff said there was no consistent system to track PASARR visits or records. The facility also did not complete a PASARR Level II reassessment for another resident after a new diagnosis of major depressive disorder was added, even though the MDS nurse said a Form 1012 should have been completed.
A resident with severe cognitive impairment, positive PASRR status, and a need for a manual wheelchair was identified by the IDT and PCSP as requiring a customized manual wheelchair (CMWC). Facility records and the PASRR Compliance Call Report showed that the NF was required to submit an NFSS request for this specialized service in the LTC Online Portal within 20 business days of the IDT meeting, but the Simple LTC PASRR NFSS Activity Portal History and staff interviews confirmed the request was not submitted until well after the required timeframe. The Director of Therapy, identified by the DON and Administrator as responsible for meeting this deadline, acknowledged the late submission as an oversight, resulting in noncompliance with the facility’s PASRR policy and regulatory timeframes for specialized services authorization.
A resident with Parkinson’s disease, moderate cognitive impairment, psychotic disorder, depression, and anxiety had an outdated PASARR PL1 that still indicated no mental illness. The MDS Coordinator stated she was responsible for keeping PL1s accurate and updated but was unaware of the psychotic disorder diagnosis, and no additional PL1 screening was available in the record.
PASARR Screening Not Updated for Mental Illness Diagnoses: The facility did not ensure PASARR Level I screenings accurately reflected the mental health status of 2 residents. One resident had schizophrenia and anxiety disorder documented, and another had PTSD, schizoaffective disorder, depressive type, and other psychiatric diagnoses, but both PASARR screens indicated no mental illness. MDS staff, the DON, and the ADM stated MDS was responsible for accurate PASARR completion and that diagnoses such as schizophrenia, major depressive disorder, severe anxiety, and PTSD would trigger a positive PASARR.
Failure to complete a new PASRR review after a resident developed additional psychiatric diagnoses. A resident with severe cognitive impairment, total ADL dependence, and ongoing psych services had a prior PASRR Level 1 that was negative for MI, ID, DD, or dementia as the primary diagnosis. The record later showed recurrent MDD, GAD, mood disorder with mixed features, and adjustment disorder, with orders for antidepressants, anxiolytic medication, Depakote, and behavior/side effect monitoring. The MDS Coordinator said she did not submit a new PE because she believed the resident would not qualify.
A resident with dementia, depression, anxiety, and bipolar disorder was not referred for a new PASRR review after receiving a new bipolar dx. Records showed a prior PL1 was negative, while the MDS, care plan, and physician orders documented the psychiatric dx and use of a mood stabilizer. Interviews confirmed the prior MDS coordinator should have completed the required form 1012 and submitted a new PL1/PE if needed.
PASRR screening was not coordinated correctly for a resident with PTSD and intact cognition. The resident's PASRR Level I form showed no mental illness despite hospital records documenting PTSD, and staff gave conflicting accounts of who entered and corrected PASRR information in the facility software. The DON stated she was responsible for overseeing PASRR completion, and the Administrator said the facility followed Texas PASRR guidelines without a PASRR policy.
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