Failure to Notify State Authority After Significant Change in Mental Health Condition
Penalty
Summary
The facility failed to notify the appropriate state mental health or intellectual disability authority after a significant change in the mental condition of a resident with a new diagnosis of major depressive disorder. The resident was originally admitted with no indication of serious mental illness or intellectual disability, as documented in the initial PASRR screening. However, after a new diagnosis of major depressive disorder was made, there was no evidence that a Level II PASRR evaluation request was properly completed, signed, or submitted to the state agency. The documentation provided lacked signatures, patient identification, and proof of transmission, and no Level II evaluation or determination was available by the end of the survey. Interviews with facility staff, including the DON and ADON, revealed that the process for identifying and referring residents with new mental health diagnoses relies on provider communication and internal notification. Despite this, the required referral and documentation for the resident's significant change in condition were not completed according to policy and regulatory requirements. The facility's policy mandates that residents with new or suspected mental disorders or intellectual disabilities be referred for a Level II PASRR evaluation, but this process was not followed in this case.