Failure to Initiate PASARR Referral After New Psychotropic Use and Psychotic Disorder
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program by not initiating a new PASARR screening for one resident after a significant change in mental health status and qualifying psychotropic medication use. Facility clinical guidelines stated that while admitted, if a resident has a change in condition, a PASARR evaluation may be required when there is a significant change in mental or physical health status since the last evaluation, or if serious mental illness, intellectual disability, or a related condition is suspected and not previously identified. A PASARR Level I completed on 6/13/25 for this resident documented no mental health diagnoses, no mental health medications, and that no further screening was required. The resident was admitted on 7/25/25, and on 7/27/25 a physician ordered quetiapine, an antipsychotic, at bedtime for psychosis. An admission MDS dated 7/31/25 documented a psychotic disorder, current use of antipsychotic and antidepressant medications, and receipt of 45 minutes of psychological therapy on one day. Between 9/15/25 and 10/15/25, a physician ordered lorazepam, an anti-anxiety medication, as needed for agitation, anxiety, and psychosis. During an interview on 9/22/25, the Social Services Director confirmed that no PASARR referral had been made for this resident, and this finding was later reviewed with the NHA, DON, and Corporate Nurse during the exit conference.
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