F0644

D

Failure to Request Level II PASRR After New Serious Mental Health Diagnoses

Hickory, North Carolina Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to request a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a resident was given new diagnoses of serious mental health disorders. The resident had a Level I PASRR completed prior to or at admission, and the annual MDS later indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. However, the resident’s cumulative diagnoses list showed active diagnoses of Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder, recurrent severe without psychotic features, both added after admission. The resident’s care plan documented a possible history of an unknown traumatic event or experience, signs and symptoms of PTSD, and recent suicidal ideations, with interventions focused on meaningful activities, reducing known trauma triggers, and using techniques such as art to reminisce on positive memories.

A psychiatric progress note documented ongoing treatment for major depressive disorder and PTSD, with the resident prescribed citalopram and instructions to continue monitoring for symptoms. Despite these documented serious mental health diagnoses and ongoing psychiatric treatment, review of the medical record revealed no Level II PASRR evaluation, and the facility could not provide documentation that a request for such an evaluation had been submitted. In an interview, the social worker stated that when the PTSD diagnosis was added, she reviewed the record, saw no new behaviors, and therefore did not request a Level II PASRR screen, and she could not find any record of a Level II PASRR request. The administrator stated that his expectation was that a Level II PASRR be requested when indicated by a new psychiatric diagnosis.