Failure to Recognize and Report Change in Condition Resulting in Delay of Care
Summary
Nursing staff failed to recognize and report a significant change in condition for one of eight sampled residents, who had multiple complex medical diagnoses including atrial fibrillation, aortic valve disorder, bilateral pneumonia, COPD, and several mental health conditions. The resident was cognitively intact and responsible for their own care decisions. On the date in question, the resident's blood pressure was recorded at a significantly low level (82/64 mmHg), with documentation noting the abnormal value but lacking details such as multiple measurements or the resident's position during assessment. Although there was a physician order to push fluids, there was no documentation indicating that the resident was sent for further evaluation at that time. Later that evening, police were called to the facility, and after discussions with the resident and their daughter, the resident requested to be sent to the hospital due to concerns about a possible allergic reaction. The medical director was notified, and EMS was called to transfer the resident. The Director of Nursing confirmed that the facility's policy for notification of changes in condition was not followed, and acknowledged that the resident experienced a delay in care and should have been sent to the hospital earlier. The resident was subsequently admitted to a local hospital for an extended period and expressed dissatisfaction with the care received at the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to submit a Level II PASRR reevaluation after a resident with a prior Level II PASRR had a significant change in condition. The resident had anxiety, bipolar disorder, depression, and PTSD, and the MDS showed serious mental illness and/or ID-related conditions with ongoing psychotropic meds. The MDS coordinator confirmed the reevaluation request was not submitted, and the Administrator stated such requests are required when a resident has a significant change.
A resident with no cognitive impairment developed loose stools, rectal pain, weakness, and refusal to eat or drink because food worsened her symptoms. Nursing notes showed the resident’s complaints persisted for several days before the provider was notified, despite repeated reports of internal rectal pain, burning, and inability to sit up. The resident and family stated staff mainly offered Imodium and did not respond to her concerns, and the resident was later sent to the ER after the NP noted buttock inflammation and concern for cellulitis.
Failure to notify the state mental health authority after significant mental health changes for two residents. One resident with CHF, malnutrition, and muscle weakness later developed depressed mood, disorganized and tangential thinking, and assaulted a roommate; another resident with metabolic encephalopathy and cognitive communication deficit was later diagnosed with adjustment disorder with anxiety. Neither record documented the required PASRR-related notification, and the MDS nurse and nursing staff did not notify the Medical Records Director of the changes.
A resident with an initial PASRR Level 1 showing no serious mental illness later developed new diagnoses of depression and anxiety, with psych eval findings and an order for escitalopram. The chart had no evidence that MDS staff completed and submitted a new Level 1 PASRR after the significant change in mental condition, and both the MDSA and DON confirmed this should have been done.
Failure to Request Level II PASRR Reevaluation After Significant Change: A resident with schizoaffective disorder, dementia with psychotic disturbance, and unspecified psychosis had a Level II PASRR with no expiration date, and a significant change MDS identified serious mental illness and/or ID-related conditions. The SW Assistant did not submit a Level II PASRR reevaluation request, stating she believed it was only needed if the change directly related to the mental illness and that the resident's mental status had not changed; the Administrator stated reevaluation requests should be made when a resident has a significant change in condition.
A resident admitted with depression and schizoaffective disorder had multiple significant change MDS assessments, but the EHR did not show a new Level I PASARR was completed with each change. Social Services stated PASARR screenings were completed before admission, but no new screening was done when the resident had a significant change in condition, and the state mental health authority coordinator was not notified.
Failure to Submit PASRR Reevaluation After Significant Change
Penalty
Summary
The facility failed to submit a request for a Level II PASRR reevaluation after a resident with a prior Level II PASRR had a significant change in physical or mental status. Resident #90 was admitted with diagnoses including anxiety disorder, bipolar disorder, depression, and PTSD. A PASRR Level II Determination Letter dated 12/08/23 showed the resident had a Level II PASRR with no effective date and that nursing facility placement was appropriate. A significant change MDS assessment dated [DATE] identified Resident #90 as having a serious mental illness and/or intellectual disability or other related conditions, with active psychiatric and mood disorder diagnoses including anxiety disorder, depression, bipolar disorder, and PTSD. The resident also received antipsychotic, antidepressant, and antianxiety medications during the assessment period. Review of the medical record found no evidence that a Level II PASRR reevaluation request was submitted after the significant change assessment. During interviews, the MDS Coordinator confirmed she was responsible for submitting these requests and stated she did not submit one for this resident, describing it as an oversight. The Administrator stated that Level II PASRR reevaluation requests should be made when a resident has a significant change in condition per regulatory guidelines.
Failure to Timely Notify Provider of Resident’s Significant Change in Condition
Penalty
Summary
The facility failed to notify the medical provider of a significant change in condition for one resident who reported loose stools, rectal pain, weakness, and not eating or drinking because it hurt her intestine and rectum. The resident’s record showed she had no cognitive impairment, used a walker independently, and was continent of bowel and bladder. Her care plan identified pain, decreased strength, assistance with hygiene, and fall risk. She also had a history that later included congestive heart failure, failure to thrive, anemia, swollen legs, chronic kidney disease, and diabetes. The resident told nursing staff she had loose stool for several days, but provider notification did not occur until three days later. On the first documented night, the nurse offered Imodium, which the resident declined, and noted the provider would be updated the next day; however, there were no progress notes for that day. Subsequent nursing notes documented ongoing loose stool, rectal burning and pain, weakness, shortness of breath, and refusal to eat because food worsened the stool and pain. The resident stated staff were only offering Imodium and were not helping her, and family reported she had been sick since the prior Friday and could not eat because food passed right through her. The provider was first updated after the resident had already experienced several days of symptoms. The NP later documented buttock pain, inability to sit up, localized soft tissue inflammation, and concern for cellulitis, with instructions to give Imodium, encourage food and fluids, and send the resident to the ER if she did not improve. The resident was ultimately sent to the hospital, where she reported a rectal wound infection that had spread to her blood. The facility policy required staff to assess changes in condition, report findings to the supervisor or DON if the resident refused examination, update the provider, contact family, and document findings, interventions, and orders.
Failure to Notify State Mental Health Authority After Significant Mental Health Changes
Penalty
Summary
The facility failed to notify the state mental health authority for two sampled residents who had significant changes in mental health status. One resident was admitted with CHF, malnutrition, and muscle weakness, had a PASRR Level 1 screening showing no need for a Level 2 screening due to negative SMI, later developed mood symptoms and was diagnosed with adjustment disorder with depressed mood, then showed disorganized and tangential thought processes and became upset and physically attacked his roommate after a war movie was being watched in the shared room. The medical record did not document notification to the state mental health authority regarding this change in mental health status. A second resident was admitted with metabolic encephalopathy and cognitive communication deficit, had a PASRR Level 1 screening showing no need for a Level 2 screening due to negative SMI, and was later diagnosed with adjustment disorder with anxiety. The record did not document notification to the state mental health authority regarding this significant change in mental health status. During interview, the Medical Records Director stated she was responsible for ensuring PASRR processes were completed and that the MDS nurse and nursing staff were responsible for notifying her when residents experienced significant mental health changes requiring renewed PASRR referral, but she had not received notification regarding either resident.
Failure to Complete PASRR Level 1 Screening After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a new PASRR Level 1 screening was completed and submitted to the state mental health authority after a resident experienced a significant change in mental condition. Resident 1 was admitted with an initial PASRR Level 1 screening completed by the acute hospital on 5/11/2026 that indicated no serious mental illness. After admission, the resident’s record showed new diagnoses of anxiety disorder and depression dated 5/27/2026, along with an order for psychiatry/psychologic evaluation and treatment as needed and escitalopram for depression. Nursing progress notes also documented that the resident verbalized suicidal ideation with no suicidal plan on 5/15/2026. The psychological evaluation dated 5/27/2026 documented a history of depression and anxiety and recommended treatment with escitalopram. The clinical chart contained no evidence that a new Level 1 PASRR screening was completed and submitted after these mental health diagnoses were made. During interview, the MDS assistant and DON both confirmed that MDS staff were responsible for PASRR screening and submission and stated that a new Level 1 PASRR should have been completed when the resident received the depression and anxiety diagnoses. The facility was unable to provide a PASRR policy and procedure.
Failure to Request Level II PASRR Reevaluation After Significant Change
Penalty
Summary
The facility failed to submit a request for a Level II PASRR reevaluation after a significant change in condition was identified for a resident previously determined to have a Level II PASRR. Resident #9 was admitted with diagnoses including schizoaffective disorder-bipolar type, moderate dementia with psychotic disturbance, and unspecified psychosis. The NC MUST inquiry dated 07/13/21 showed the resident had a Level II PASRR with no expiration date, and a significant change MDS assessment dated [DATE] identified the resident as having a serious mental illness and/or intellectual disability or other related conditions. The resident's active psychiatric and mood disorder diagnoses included psychotic disorder and schizophrenia, and she received antipsychotic medication during the MDS assessment period. Review of the medical record found no evidence that a request for a Level II PASRR reevaluation was submitted after the significant change MDS assessment. During interview, the SW Assistant stated she was responsible for submitting Level II PASRR reevaluation requests when needed, but believed a request was only required if the significant change directly related to the mental illness. She reported she did not submit a request because the resident's mental status did not change. The Administrator stated that requests for Level II PASRR reevaluations should be made when a resident had a significant change in condition per regulatory guidelines.
Failure to Notify State Mental Health Authority of Significant Change
Penalty
Summary
The facility failed to notify the state mental health authority coordinator of a significant change in physical condition for one resident reviewed for the PASARR process. The resident was admitted with diagnoses including depression and schizoaffective disorder, and a Significant Change MDS dated 04/13/2026 documented that the resident was cognitively intact. The facility policy for the PASARR process stated that when a resident who triggers a Level II PASARR has a significant change in physical or mental condition, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority. Record review showed the resident had Significant Change MDS assessments on 11/17/2025, 02/17/2026, 03/05/2026, and 05/29/2026, but the electronic health record did not show that a new Level I PASARR was completed with each significant change MDS. In interview, the Social Services staff member stated that Level I PASARR screenings were completed prior to admission, and when asked whether a new PASARR screening was completed when the resident had a significant change in condition, stated that it was not completed.
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