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F0644
D

Failure to Coordinate PASRR Level II Evaluation After New Mental Health Diagnosis

Westminster, Colorado Survey Completed on 06-03-2025

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 changes to the Pre-Admission Screening and Resident Review (PASRR) Level II determination and evaluation report with the State Mental Health Agency when a resident received a new diagnosis of a serious mental disorder. Specifically, a resident was diagnosed with bipolar disorder by a nurse practitioner, but this new diagnosis was not promptly communicated to the State Mental Health Agency for a PASRR Level II evaluation as required by facility policy. The policy mandates re-screening for new or changed psychiatric diagnoses, but the diagnosis was not identified or acted upon during multiple quarterly care plan reviews by the social services director. The resident in question had a history of dementia with behavioral disturbances and was receiving psychotropic medication. Despite the addition of bipolar disorder to the resident's electronic medical record, there was no documentation supporting the basis for this diagnosis, and the resident was unaware of the diagnosis. The oversight was only identified during the survey, and prior to that, no updated PASRR screening had been completed in response to the new diagnosis.

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