Failure to Refer Resident for PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Pre-Admission Screening and Resident Review (PASARR) after the resident was diagnosed with serious mental disorders. The resident was admitted with diagnoses including heart valve replacement, atrial fibrillation, and congestive heart failure, and later received additional diagnoses of severe dementia with agitation, dementia with psychotic disturbance, and schizoaffective disorder, depressive type. Despite these new diagnoses, the resident's PASRR Level I screening from a previous date indicated no serious mental illness or intellectual/developmental disability, and no further screening was conducted after the significant change in the resident's mental health status. The resident's care plan documented risks related to impaired cognitive skills, mental health diagnoses, and behaviors such as physical aggression and elopement risk, with the resident residing on a secured unit. The facility's policy required notification to the state-designated mental health or intellectual disability authority when a resident experiences a significant change in mental health status, but this was not done. The social worker acknowledged missing the re-evaluation and only began gathering documentation for the PASARR after the deficiency was identified.