Failure to Refer Resident for PASRR Level II Evaluation After Psychiatric Hospitalization
Penalty
Summary
The facility failed to refer a resident with newly evident serious mental health issues for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. The resident, who had a diagnosis of major depressive disorder, was admitted to the facility and subsequently experienced a suicide attempt, leading to transfer to a community emergency department and involuntary commitment to a psychiatric hospital for evaluation and stabilization. Upon readmission to the facility, there was no documented evidence that the facility initiated a PASRR Level II referral through the state mental health authority, despite the resident's significant change in condition and emergence of serious maladaptive behaviors. Staff interviews and clinical record reviews confirmed that the facility did not communicate the need for a PASRR Level II evaluation following the resident's psychiatric hospitalization and readmission. This omission was acknowledged by the Nursing Home Administrator, who confirmed that the required referral was not made after the resident's suicide attempt and subsequent return to the facility.