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F0644
D

Failure to Refer Resident for PASARR Screening After New Mental Health Diagnosis

San Antonio, Texas Survey Completed on 04-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who was newly diagnosed with a serious mental disorder. Specifically, after a resident was diagnosed with persistent mood disorder and major depressive disorder, the facility did not refer the resident for a Level I PASARR screening as required. The resident's medical record showed multiple psychiatric diagnoses and ongoing treatment with several psychotropic medications, yet no referral was made for further evaluation through the PASARR process. During an interview, the Director of Nursing (DON) acknowledged responsibility for referring residents for Level I PASARR screening if they had a mental illness but stated she did not believe the resident had a psychiatric condition warranting the referral. The DON also indicated she had not consulted with the psychiatric nurse practitioner regarding the resident's condition. Upon reviewing the psychiatric assessment, the DON recognized that the resident could qualify for additional resources and admitted that not referring residents with mental illness for Level I evaluation could result in missed services. Facility policy requires adherence to PASARR guidelines to ensure residents with mental illness receive specialized services.

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