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F0644
D

Failure to Coordinate PASRR Assessment After New Mental Health Diagnosis

Dallas, Texas Survey Completed on 05-15-2025

Penalty

Fine: $24,845
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for one resident who was reviewed for PASRR assessments. The resident, a male with a history of depression disorder, anxiety disorder, psychotic disorder, and non-Alzheimer's dementia, was admitted with severe cognitive impairment. He received a new diagnosis of schizoaffective disorder, bipolar type, but the facility did not refer him to the appropriate state-designated mental health authority for review as required. The resident's PASRR Level 1 screening, completed previously, did not indicate a mental illness, and a subsequent 1012 Form listed a primary diagnosis of dementia, but sections of the form were incomplete. Interviews with facility staff revealed confusion regarding the need for a new PASRR evaluation following the new diagnosis. The Resident Care Coordinator (RCC) initially believed the dementia diagnosis on the 1012 Form overrode the new mental health diagnosis, but later acknowledged the form was not completed correctly and that a new PASRR Level 1 or 1012 Form should have been completed. The Director of Nursing (DON) confirmed that a new PASRR evaluation should be done when a new diagnosis is given. The facility's admission policy requires all new admissions and readmissions to be screened for mental disorders per the PASRR process.

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