Failure to Refer Resident for Level II PASRR After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a newly evident or possible serious mental disorder was referred to the appropriate state-designated mental health authority for a Level II PASRR screening. The resident was originally admitted with a Level I PASRR indicating anxiety but no need for further review. Later, a new Level I PASRR was completed due to additional mental health concerns, including suspected mental illness and adjustment disorder with anxiety, and was sent for a second-level review, which determined the resident did not have a serious mental illness. However, subsequent documentation in the resident's medical record showed a new order for Seroquel for schizophrenia and psychiatric provider notes indicating a diagnosis of dementia with behavioral delusions and a rule out for schizophrenia. Despite these new findings, the PASRR was not updated or sent for review for the newly diagnosed or suspected condition of schizophrenia, as confirmed by the Social Services Director during an interview.