Failure to Notify State Authorities and Complete PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the State Mental Health authority or the State Intellectual Disability authority when a resident was newly diagnosed with Paranoid Schizophrenia. The resident, who had a history of bipolar disorder, unspecified dementia with behavioral disturbance, and post-traumatic stress disorder, was diagnosed with Paranoid Schizophrenia and Schizophreniform Disorder on December 3, 2024. A review of the clinical record showed there was no documentation that a Preadmission Screening and Resident Review (PASARR) was completed following the new diagnosis, nor was there evidence that the California Department of Health Services or the State Mental Health Department were notified as required. Interviews with facility staff, including the DON and the MDS Coordinator, confirmed that the responsibility for making such notifications and referrals lies with the MDS Coordinator. The MDS Coordinator acknowledged the requirement to notify the appropriate state authorities and complete a new PASARR when a resident is identified with a new mental disorder diagnosis or experiences a significant change in status. However, the MDS Coordinator could not explain why these actions were not taken for this resident. Review of the facility's policy and procedure confirmed the requirement for prompt notification and PASARR completion, which was not followed in this instance.