Failure to Refer Residents with New Mental Health Diagnoses to PASRR Agency
Summary
The facility failed to refer two residents to the state-designated Pre-Admission Screening and Resident Review (PASRR) agency after each was diagnosed with a new mental health condition. According to the facility's policy, any assessment revealing a mental health disorder should be addressed, including referral to the PASRR agency. Medical record reviews showed that one resident, who was already diagnosed with Schizoaffective Disorder, Depression, and Anxiety, received a new diagnosis of Adjustment Disorder, while another resident with a history of Major Depression, Anxiety Disorder, and Insomnia was newly diagnosed with Psychotic Disorder. In both cases, the facility did not make the required referral to the PASRR agency following these new diagnoses. Both residents were found to be cognitively intact based on their Brief Interview for Mental Status (BIMS) scores. The Director of Nursing confirmed during an interview that the facility did not refer these residents to the PASRR agency after the identification of new mental health conditions, despite the facility's policy and regulatory requirements. This lapse was identified through policy review, medical record review, and staff interviews.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
The facility failed to request Level II PASRR reevaluations for two residents with serious mental illness after significant changes in condition were identified on MDS significant change assessments. Both residents had existing Level II PASRR determinations with no expiration date and were receiving psychotropic medications, yet NC MUST records showed no reevaluation requests following the documented changes. The SW, who was responsible for PASRR submissions, reported being unaware that a significant change in condition required a Level II PASRR reevaluation, and the Administrator confirmed that the SW was designated to review diagnoses and request reevaluations per regulatory guidelines.
A resident with multiple psychiatric and cognitive diagnoses, including dementia, had an existing PASRR Level II determination and later experienced a significant change in condition, including initiation of hospice care, as documented on a comprehensive MDS and CAA for cognitive loss/dementia. Although the MDS nurse recognized that this resident, listed as a PASRR Level II case, should have been referred for a PASRR re-evaluation after the significant change assessment, no referral was made. The Director of Social Services confirmed she did not submit a PASRR re-evaluation request, stating she believed it was unnecessary because the resident already had a Level II PASRR status, resulting in the facility’s failure to notify the appropriate authorities for a required PASRR Level II re-evaluation.
A resident with a diagnosis of Major Depressive Disorder and a positive Level II PASARR screening did not receive a timely referral for specialized services, as required. Despite recommendations and approvals for therapies, the facility failed to notify the appropriate authorities and initiate PASARR services within the mandated timeframe, as confirmed by staff interviews and record review.
A resident with multiple diagnoses and moderate cognitive impairment had abnormal urinalysis results indicating possible infection, but the facility failed to notify the physician or responsible party and did not document the change in condition as required by policy.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Failure to Request PASRR Level II Reevaluations After Significant Changes in Condition
Penalty
Summary
The facility failed to request Level II PASRR reevaluations after significant changes in condition for residents already determined to have Level II PASRR status. One resident with schizoaffective disorder, bipolar type, and anxiety disorder had a Level II PASRR determination with no expiration date and was identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and schizophrenia, and receiving antipsychotic and antidepressant medications. Despite this significant change assessment, a review of the NC Medicaid Uniform Screening Tool (NC MUST) showed that no PASRR reevaluation request had been submitted following the significant change. Another resident with major depressive disorder and anxiety disorder also had a Level II PASRR determination with no expiration date and was similarly identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and depression and receiving antianxiety and antidepressant medications. NC MUST records again showed no PASRR reevaluation request after the significant change assessment. During interviews, the Social Worker, who was responsible for submitting Level II PASRR reevaluation requests, stated she was still learning the PASRR process and was not aware that a reevaluation request was required when a resident had a significant change in condition. The Administrator confirmed that the Social Worker was responsible for reviewing diagnoses and requesting Level II PASRR reevaluations when residents experienced significant changes in condition per regulatory guidelines.
Failure to Request PASRR Level II Re-evaluation After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to request a Level II Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in condition for a resident with a prior Level II PASRR determination. The resident was admitted with multiple psychiatric and cognitive diagnoses, including non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and psychotic disorder, and had a PASRR Level II Determination Notification dated 11/14/23, with a PASRR number ending in H indicating a halted Level II determination due to a primary dementia diagnosis. The resident’s electronic medical record showed a hospitalization and a subsequent significant change comprehensive MDS assessment, which documented that the resident was receiving hospice care. The Care Area Assessment for Cognitive Loss/Dementia also noted that the resident was now under hospice care. The facility’s current list of PASRR Level II residents identified this resident as having Level II status. During interviews, the MDS nurse acknowledged awareness that the resident was a Level II PASRR resident and stated that the resident should have been referred for a PASRR re-evaluation when the significant change MDS was completed, and that the resident had been on the original list of those needing a PASRR referral. However, the MDS nurse did not know whether Social Services had actually made the referral. The Director of Social Services reported that she did not submit a PASRR re-evaluation request for this resident following the significant change MDS, explaining that she believed a referral was unnecessary because the resident already had a Level II PASRR status. As a result, no PASRR Level II re-evaluation was requested despite the documented significant change in the resident’s physical and/or mental status and initiation of hospice care.
Failure to Timely Refer Resident for PASARR Specialized Services
Penalty
Summary
The facility failed to notify the appropriate state mental health or intellectual disability authority promptly after a significant change in the condition of a resident with a mental illness, as required for PASARR (Preadmission Screening and Resident Review) processes. Record review showed that a male resident with a diagnosis of Major Depressive Disorder had a positive Level II PASARR screening and was recommended for specialized services, including physical, occupational, and speech therapy. Despite these recommendations and approvals for services, the facility did not ensure that the resident was referred to PASARR services within the required timeframe. The care plan did not indicate whether the resident received PASARR services, and documentation revealed the resident had been PASARR positive for several years. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, confirmed that the referral for PASARR services was not sent within the required 20-day period following the IDT meeting. Staff acknowledged that this delay or omission could result in the resident not receiving necessary specialized services. Facility policy required notification to the Local Intellectual and Developmental Disability Authority (LIDDA) within two days of admission for positive PASARR screenings, but this process was not followed for the resident in question.
Failure to Notify Physician and Document Significant Change in Condition
Penalty
Summary
The facility failed to notify a physician after a significant change in condition for a resident who exhibited abnormal laboratory results. The resident, who had diagnoses including metabolic encephalopathy, hypertension, and dementia, was dependent on staff for activities of daily living and had moderate cognitive impairment. A urinalysis revealed several abnormal findings, including turbid urine, moderate blood, positive protein, large leukoesterase, elevated white blood cells, and moderate bacteria, all of which were flagged as abnormal. Despite receiving these abnormal lab results, the Registered Nurse Supervisor confirmed that there was no documented evidence that the physician or the resident's responsible party was notified. Additionally, there was no documentation of an SBAR (Situation, Background, Assessment, Recommendation) or progress notes indicating that the physician had been informed, even though the nurse had received the results. The Director of Nursing also confirmed that abnormal urinalysis results are considered a significant change in condition and require prompt notification of the physician and responsible party, as well as proper documentation, none of which occurred in this case. A review of the facility's policies and procedures indicated that staff are required to promptly notify the attending physician and the resident's representative of any significant changes in the resident's condition, including abnormal lab results. The policies also require documentation of how, when, and to whom the information was provided. In this instance, the required notifications and documentation were not completed, resulting in a deficiency.
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