Failure to Conduct Level II PASRR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis for a Level II PASRR, which is required when there is a significant change in a resident's mental health condition. The resident, identified as R19, was admitted with diagnoses including major depressive disorder, anxiety disorder, and seizures. On October 5, 2024, R19 was diagnosed with unspecified psychosis, a condition that necessitates a Level II PASRR referral. However, the facility did not complete a rescreening for R19 following this new diagnosis. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process. The Admissions Coordinator, V26, stated she had never submitted a re-screening for a resident's Level I PASRR following a new mental health diagnosis. The Social Services Director, V24, indicated he was not involved in the PASRR process and could not access the necessary system. The Director of Nursing, V2, acknowledged the new diagnosis but stated she was not involved in PASRRs. The facility's policy requires a new screen to be submitted if changes occur or new information refutes previous findings, but there was no documentation of a rescreening for R19 after the diagnosis of psychosis.