Failure to Refer Resident for Level II PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) after new diagnoses of serious mental illnesses were identified. The resident was initially admitted with a Level I PASRR determination that did not require further screening unless a significant change in mental health status occurred. Subsequent medical record reviews showed that the resident was diagnosed with bipolar disorder and later with major depressive and generalized anxiety disorders. Despite these new diagnoses, there was no evidence that a Level II PASRR referral was completed as required. Interviews with facility staff revealed gaps in communication and notification processes. The Social Worker, responsible for completing Level II PASRR screenings, was unaware of the new mental health diagnoses and stated she typically relied on notifications from the MDS nurse or DON. The DON indicated that the medical record system was supposed to alert the Social Worker to new mental health diagnoses but was unsure why this did not occur in this case. The Administrator was also unaware that the required referral had not been completed.