Failure to Obtain Updated PASRR Level II After New Schizophrenia Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to coordinate with the PASRR program by not obtaining an updated Level II PASRR after a resident was diagnosed with Schizophrenia. The facility’s PASRR policy dated 2/2/24 states that any Level II resident who experiences a significant change in status, or any resident who exhibits a newly evident or possible serious mental disorder, must be promptly referred to the State mental health authority for a Level II resident review. The resident was originally admitted with diagnoses including Bipolar Disorder and Obsessive-Compulsive Personality Disorder and later readmitted with Schizoaffective Disorder and Post-Traumatic Stress Disorder. A PASRR Level I dated 10/16/24 listed mental health diagnoses of Major Depression and Bipolar Disorder, and a PASRR Level II dated 10/19/24 identified conditions including Depression, Bipolar Disorder, Major Depressive Disorder with psychotic features, Anxiety Disorder, and Post-Traumatic Stress Disorder, with recommendations for routine mental health follow-up and specific psychotropic medications. On 1/21/25, the resident was diagnosed with Schizophrenia, and the current care plan reflects the use of psychotropic medications for Major Depressive Disorder, Anxiety, Schizophrenia, Obsessive-Compulsive Disorder, and Post-Traumatic Stress Disorder. However, review of the medical record on 1/14/26 showed no evidence that the facility obtained an updated Level II PASRR after the Schizophrenia diagnosis. The Admissions Coordinator stated she is responsible for PASRR screenings on admission and with updates but is not in the building full time and relies on facility staff to notify her or the Social Service Director when new diagnoses are added so residents can be re-screened. She confirmed that all mental illness diagnoses should be included on Level I and Level II screenings. The Administrator in Training acknowledged that the resident had the diagnosis of Schizophrenia before 1/21/25, but it was not identified in the chart until an audit after a change of ownership, and that a new Level II PASRR was not requested despite the documented diagnosis.
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