Failure to Notify State Agency of Significant Change in Mental Health Condition
Penalty
Summary
The facility failed to notify the appropriate state agency, the Ohio Department of Mental Health, of a significant change in a resident's mental health condition as required by regulation. Record review showed that a resident was admitted with multiple diagnoses, including anxiety and epilepsy, and later received new diagnoses of disorganized schizophrenia and schizophrenia. Despite these new mental health diagnoses and an increase in behaviors, there was no evidence in the medical record that an updated PASRR assessment was completed or that the state agency was notified. Staff interviews confirmed that no updated PASRR was completed at the time of the new diagnoses, and the Director of Nursing acknowledged that a PASRR should have been conducted. Facility policy requires prompt referral to the state mental health authority for a level II resident review when a resident exhibits a newly evident or possible serious mental disorder. The failure to follow this policy and regulatory requirement resulted in the deficiency.