Failure to Refer Resident for PASARR Level II Evaluation After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed serious mental illness for a Pre-admission Screening and Annual Resident Review (PASARR) Level II evaluation. The resident was admitted with a diagnosis that included bipolar disorder, and medical records showed a new diagnosis of bipolar disorder was documented shortly after admission. A physician's order was placed for Depakote to address mood symptoms related to this diagnosis. Despite these developments, the annual Minimum Data Set (MDS) assessment indicated the resident was not considered by the state PASARR Level II process to have a serious mental illness, and no referral for a Level II evaluation was made. Interviews with facility staff, including the MDS Coordinator, Social Services Director (SSD), Corporate MDS Director, Administrator, and Director of Nursing (DON), confirmed that the process for referring residents with new serious mental health diagnoses for PASARR Level II screening was not followed. The SSD, who was responsible for making such referrals, acknowledged the oversight and could not provide an explanation for why the referral was missed. Other staff members confirmed their expectation that the referral should have been made according to regulatory guidance.