Failure to Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed mental illness for a Level II PASARR evaluation. The resident, who had a history of bipolar disorder, was diagnosed with schizoaffective disorder. Despite this significant change in diagnosis, there was no evidence that the facility re-evaluated the resident for a PASARR Level II, as required by their policy. The policy mandates that a significant change Level 1 screening should be completed when a resident receives a new mental diagnosis or begins receiving medications for mental illness, followed by a call to the Level of Care Evaluation Unit to determine if a Level 2 screening is necessary. The deficiency was identified during a review of the resident's clinical records and interviews with the facility's administrator. The administrator acknowledged the lack of documentation showing that the OHCA was contacted following the new diagnosis. The facility had undergone a change in ownership, which contributed to the difficulty in determining the previous process for handling such cases. The resident was cognitively intact, as indicated by a BIMS score of 15, and was receiving antipsychotic and antidepressant medications at the time of the assessment.