Failure to Complete PASRR Level II Referral After Significant Change in Mental Status
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II referral after a significant change in mental status for a resident with a history of mental disorder, schizophrenia, major depressive disorder, and cognitive communication deficit. The resident was readmitted with these diagnoses and had a documented severe cognitive impairment, as indicated by a BIMS score of 0 out of 15. A psychiatric evaluation was conducted due to self-injurious behaviors and aggression towards others, resulting in recommendations to adjust the resident's medications and to evaluate the appropriateness of the current level of care. Despite these significant behavioral changes and multiple documented incidents of self-harm and aggression, no PASRR Level II referral was made. Staff interviews revealed that the Social Services Director was aware of the resident's increased behaviors but did not consider the need for a PASRR Level II referral. The Director of Nursing also acknowledged awareness of the behaviors and participation in the psychiatric meeting but was unsure of the PASRR process. The facility's policy requires prompt referral to the state mental health or intellectual disability authority for any Level II resident experiencing a significant change in status, which was not followed in this case.