Failure to Refer for Level II PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASRR) following a new diagnosis of schizoaffective disorder, bipolar type. The resident, who had a history of hemiplegia, chronic heart failure, and moderate cognitive impairment, was admitted and later readmitted to the facility with no initial indication of a serious mental disorder according to the original PASRR Level I evaluation. However, subsequent medical records showed a new diagnosis of schizoaffective disorder, bipolar type, and the resident was prescribed antipsychotic medication for this condition. Despite the new diagnosis, there was no documentation of a referral to the local mental health authority for a Level II PASRR evaluation, as required when a significant change in mental health status occurs. The Director of Nursing confirmed that the diagnosis should have triggered a referral, but the corporate MDS coordinator, who identified the diagnosis in the absence of the facility's MDS coordinator, did not inform the facility or submit the necessary H&HS Form 1012. Facility policy required coordination with the PASRR program for individuals with mental disorders, but this process was not followed in this case.