Failure to Complete PASRR Level II Referral After Return of Serious Mental Illness
Penalty
Summary
The facility failed to complete a PASRR Level II referral for a resident who experienced a return of serious mental illness after admission. The resident, with a history of schizoaffective disorder, was initially determined not to require specialized services following a PASRR Level II assessment. After a psychiatric evaluation considered the disorder resolved, a gradual dose reduction of antipsychotic medication was initiated. Despite ongoing antipsychotic use and cognitive impairment, a significant change in status MDS assessment did not indicate the presence of serious mental illness. Over the following weeks, the resident exhibited escalating behavioral changes, including agitation, verbal outbursts, territorial guarding, and physical aggression, culminating in an incident where the resident physically assaulted a roommate. Subsequent psychiatric evaluation confirmed the return of psychotic symptoms and resulted in a re-diagnosis of schizoaffective disorder. The resident's medication regimen was adjusted, and the diagnosis list was updated to reflect active schizophrenia. Observations documented ongoing behavioral disturbances, and staff interviews confirmed increased aggression and territoriality, particularly after the medication dose reduction. The facility's policy did not address the process for PASRR assessment following the reemergence of serious mental illness post-admission, and there was no documentation of a PASRR Level II referral being initiated or completed after the resident's condition changed.