Failure to Refer New Mental Health Diagnosis for Level II Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to refer a newly identified mental health diagnosis to the appropriate state-designated mental health authority for a Level II evaluation, as required by policy. The clinical record review for one resident revealed that although a previous Level II evaluation had been completed for a diagnosis of delusional disorder, a new diagnosis of schizoaffective disorder was identified several months later without evidence of a subsequent referral for reassessment. The facility's policy mandates prompt notification to the state mental health authority after a significant change in mental or physical condition for residents with mental disorders. The resident involved had a history of schizoaffective disorder, mild cognitive impairment, and delusional disorder, and was assessed as severely cognitively impaired but independent in certain activities of daily living. The care plan noted ongoing psychosocial distress and the use of antipsychotic medication, with interventions including evaluation for psychiatric or behavioral health consults. During interviews, the social worker indicated she was unaware that a new referral was required for a new mental health diagnosis in a long-term care resident with a prior Level II evaluation, leading to the failure to initiate the necessary referral process.