Failure to Refer for PASRR Level II Assessment After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed major depressive disorder, recurrent and severe, for a PASRR Level II assessment following a significant change in status. The resident, an adult male with Huntington's Disease, depressive episodes, anxiety disorder, and major depressive disorder, was admitted with these diagnoses, and the onset of major depressive disorder was documented at admission. Despite this, the most recent PASRR Level I screening, completed prior to admission, was negative for mental illness, and no subsequent Level II referral was made after the new diagnosis was identified. Interviews with facility staff, including the MDS nurse, Assistant DON, DON, and Administrator, confirmed that the responsibility for PASRR evaluations lies with the MDS nurse and that a Level II referral should have been completed for the new diagnosis. The facility's policy requires review and submission of the PASRR Level I screening form prior to admission, but there was no evidence of a Level II referral after the significant change in the resident's mental health status.