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F0646
D

Failure to Notify State Mental Health Authority After Significant Change in Resident's Condition

Lexington, North Carolina Survey Completed on 08-28-2025

Penalty

No penalty information released
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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 notify the State Mental Health Authority after a resident with a diagnosis of bipolar disorder and generalized anxiety disorder experienced a significant change in condition. The resident had a Level I PASRR that indicated no further screening was required unless there was a significant change in mental health status or treatment needs. On review, it was found that the resident's Depakote dosage was increased and Lexapro was restarted due to increasing anxiety and behavioral changes, including refusing showers and yelling out. Interviews with facility staff revealed that the Social Worker, who was responsible for initiating Level II PASRR referrals, did not submit a request for further evaluation following the resident's change in treatment. The Social Worker acknowledged that a Level II PASRR screening should have been requested at the time of the medication changes but admitted to overlooking this responsibility. The DON and Administrator both confirmed the requirement for timely completion of PASRR determinations for residents with mental illness.

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