Failure to Notify State Authority and Request PASRR Re-Evaluations After Significant Change in Condition
Penalty
Summary
The facility failed to notify the appropriate state authorities and request required re-evaluations for residents with mental disorders or intellectual disabilities who experienced a significant change in condition. Specifically, for one resident with schizoaffective disorder, there was a documented change in behavioral symptoms, including increased agitation and psychosis, which led to new orders for antipsychotic and anti-anxiety medications. Despite these changes, the facility did not initiate a Level II PASRR screening as required when a significant change in condition occurs for individuals with mental illness. Two additional residents with serious mental illness and PASRR Level II determinations experienced significant changes in their physical or mental status, such as significant weight loss, new swallowing disorders, and functional decline. In both cases, the residents' Minimum Data Set (MDS) assessments identified these significant changes, but the facility did not request a PASRR Level II re-evaluation from the state mental health authority as required by regulation. Interviews with facility staff, including the Social Services Director, Social Worker, MDS Coordinator, Administrator, and Director of Nursing, revealed a lack of understanding and inconsistent practice regarding the requirement to notify the state authority and request PASRR re-evaluations following significant changes in condition for residents with mental illness or intellectual disabilities. This resulted in the failure to ensure appropriate notifications and screenings for all three residents reviewed who had experienced significant changes.