Failure to Notify PASRR Office After Significant Change in Mental Condition
Penalty
Summary
The facility failed to promptly 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 originally admitted with a diagnosis of depression and had a negative screen for serious mental illness, with no Level II PASRR evaluation indicated at admission. During the stay, the resident developed new diagnoses of Delusional Disorders and Hallucinations, and was started on antipsychotic medication (Seroquel) following behavioral health evaluations and physician orders. Despite these significant changes, including the addition of new mental health diagnoses and the initiation of antipsychotic treatment, the clinical record did not show any evidence that a referral to the PASRR Office for Resident Review was made. This was confirmed during an interview with the facility's Social Worker, who acknowledged that the resident should have been referred for a Resident Review at the time of the new diagnoses and medication changes.