Failure to Notify State Authorities After Significant Change in Resident with Mental Disorder
Penalty
Summary
The facility failed to identify and notify the appropriate state authorities for a Level II Preadmission Screening and Resident Review (PASARR) when a resident with a mental disorder experienced a significant change in condition. According to the facility's policy, residents with newly evident or possible serious mental disorders must be referred for appropriate services and the state mental health or intellectual disability authority must be notified promptly after a significant change in their mental or physical condition. In this case, a resident with a diagnosis of bipolar disorder and generalized anxiety disorder exhibited multiple episodes of manic behavior, which led to hospitalization in a Behavioral Health Unit. Despite these significant changes, there was no evidence in the resident's record that a PASARR Level II was completed or that the state authorities were notified. Interviews with facility staff, including the Social Service Director and the Administrator, revealed a lack of awareness regarding the requirement to notify state authorities following a significant change in condition for residents with mental disorders or intellectual disabilities. The staff confirmed that they do not conduct PASARRs in-house and were unaware of the notification requirement, even after the resident's behavioral issues and hospitalization. The deficiency was identified through record review, staff interviews, and policy review.