Failure to Notify PASRR Office After Significant Change in Mental Condition
Penalty
Summary
The facility failed to notify the state mental health authority (PASRR Office) of the need for a Resident Review when a resident experienced a significant change in mental condition from their initial Level I PASRR. The resident was admitted with diagnoses including Post-Traumatic Stress Disorder (PTSD) and Personality Disorder, but the initial PASRR screening did not document any mental illness or disorder, and a Level II PASRR evaluation was not indicated at that time. Upon admission, there were no psychotropic medications ordered for the resident. Over the following months, the resident exhibited escalating behavioral and psychiatric symptoms, including aggressive behavior, refusal of medications, physical altercations with residents and staff, sexually inappropriate behavior, and exit-seeking. The resident also began expressing both homicidal and suicidal ideation, including specific threats to harm themselves and others. Psychiatric assessments documented these changes, and the resident was eventually started on psychotropic medications, including Lamotrigine and later Sertraline, to address mood instability and depressive symptoms. Despite these significant changes in mental status and the initiation of psychotropic medication, the facility did not refer the resident to the PASRR Office for a Resident Review as required by policy and regulation. Interviews with facility staff confirmed that no referral was made, even though the social worker acknowledged that the resident's change in behavior and need for medication constituted a significant change in mental condition that should have triggered a PASRR Resident Review.