Failure to Notify State Mental Health Authority of New Onset Mental Illness
Penalty
Summary
The facility failed to notify the county (designated State Mental Health Authority) regarding two residents who developed new onset mental illness after admission. For both residents, initial Pre-Admission Screening (PAS) did not identify mental illness or the need for a Level II PASARR. However, subsequent assessments and medical records showed that both residents received new diagnoses of significant mental health conditions, including unspecified psychosis, paranoid delusional disorder, social phobia, and schizoaffective disorder. Both residents were prescribed psychotropic medications and exhibited symptoms such as depression, anxiety, psychosis, and behavioral disturbances. Despite these new diagnoses and changes in mental health status, there was no documentation in either resident's medical record indicating that the county or State Mental Health Authority had been notified as required. Interviews with facility staff revealed a lack of awareness regarding the need to refer residents with new mental illness diagnoses for Level II PASARR screening, and the facility's policy required such notification after significant changes in mental or physical condition. The deficiency was identified through interview and document review.