Failure to Refer Resident for Level II PASRR After Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) after the resident was diagnosed with Bipolar II Disorder. According to the facility's PASRR policy, the facility is required to comply with federal and state standards by requesting and maintaining complete PASRR materials, including Level II assessments, for residents with qualifying mental health diagnoses. Record review showed that the resident was admitted with a diagnosis of Depression Disorder and later diagnosed with Bipolar II Disorder, for which antipsychotic medication was prescribed. Despite this, there was no evidence in the medical record that a Level II PASRR was obtained following the new diagnosis. The Social Service Director confirmed that the PASRR II was never requested after the diagnosis of Bipolar II Disorder, as required by policy.