Failure to Refer Resident for PASRR Level II Evaluation After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation after the identification of a new serious mental health diagnosis. The resident was originally admitted with a history of alcohol abuse and depression, and the initial PASRR completed at admission did not indicate the need for a Level II Evaluation. Over time, the resident's diagnoses expanded to include dementia, anxiety, psychosis, and delusional disorder, with the diagnosis of psychosis and delusional disorder being documented on 9/26/24. A behavioral health note from 3/29/23 also indicated the presence of psychosis, but there was no evidence in the medical record that a PASRR Level II Evaluation was conducted following these new or newly evident diagnoses. During an interview, the facility's social worker confirmed that a request for a PASRR Level II Evaluation should have been made when the new mental health diagnosis was identified, but this referral was not completed as required. The deficiency was identified through record review and staff interview, which confirmed the lack of appropriate referral for further evaluation after the resident's mental health status changed.