Failure to Submit Level II PASSR Evaluation for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Level II Preadmission Screening and Resident Review (PASSR) evaluation for a resident who was diagnosed with a new mental health condition and started on a psychotropic medication. The resident, identified as Resident #17, was diagnosed with delusional disorder and was receiving the antidepressant Lexapro as part of their care plan. Despite this significant change in the resident's mental health status, the facility did not complete the required Level II PASSR evaluation, which is necessary when a resident receives a new mental health diagnosis. The deficiency was identified through a review of the resident's clinical records, staff interviews, and policy review. The Director of Nursing acknowledged the oversight in not completing the Level II evaluation for the resident following the new diagnosis and medication initiation. The facility's policy, revised in November 2024, mandates that changes in a resident's status, such as a new mental health diagnosis, require a Level II PASSR evaluation. The Administrator confirmed the expectation that such evaluations should be submitted for residents experiencing significant changes, including new mental health diagnoses or changes in psychotropic medication.