Failure to Conduct PASARR Level II Evaluation for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a resident with a new diagnosis of Bipolar Disorder was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required. According to the facility's policy, all applicants to a Medicaid-certified nursing facility must be screened for serious mental disorders or intellectual disabilities. Additionally, the facility is required to notify the state-designated mental health or intellectual disability authority when a resident experiences a significant change in mental or physical condition. However, the facility did not adhere to this policy for Resident #71, who was diagnosed with Bipolar Disorder on 11/18/2024. Resident #71's clinical record showed no evidence of a completed Level II PASARR following the new diagnosis. The resident's quarterly Minimum Data Set (MDS) indicated a Brief Interview of Mental Status (BIMS) score of 6, suggesting moderate cognitive impairment. Interviews with the social worker and the administrator confirmed that a Level II PASARR was not completed for Resident #71, despite the new diagnosis of Bipolar Disorder, which was a requirement according to the facility's policy.