Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a referral was made for a Level II PASARR evaluation for a resident who exhibited significant mental health issues. The resident, who was admitted with diagnoses of depression and anxiety, was cognitively intact but displayed verbal behaviors such as threatening, screaming, and cursing at others. The resident was also receiving antipsychotic medication. Despite these behaviors and the initiation of antipsychotic medication, the facility did not refer the resident for a Level II PASARR evaluation, which is required when a resident exhibits a newly evident or possible serious mental disorder. The resident's care plan included interventions for inappropriate physical and verbal behaviors, and the resident was diagnosed with paraphilia. A behavioral health provider noted episodes of sexual behaviors, auditory hallucinations, and delusional thinking. Despite these significant changes, the facility did not report them to the state mental health authority for a Level II PASARR assessment. Interviews with the Licensed Medical Social Worker and the Director of Nursing confirmed that no referral had been made, indicating a failure to address the resident's psychosocial needs adequately.
Plan Of Correction
Element 1: Resident #105's change in condition was submitted to OBRA on 3/17/25. Element 2: A facility-wide audit was completed by the regional social worker on 3/13/25 to ensure that no significant diagnosis or medications have been changed. Any changes identified were corrected. Element 3: The resident assessment/coordination with PASARR program policy was reviewed by the NHA and deemed appropriate on 3/17/25. The social services director/designee was re-educated regarding the resident assessment/coordination with PASARR program policy on 3/17/25. Element 4: All residents reviewed in daily clinical meeting for any new significant mental illness diagnosis or medications weekly x4 weeks and monthly 3 months. Any diagnosis or medications requiring a Level II assessment will be submitted to OBRA by social services director/designee. The NHA is responsible for achieving and sustaining compliance.