F0645

D

Failure to Obtain Level II PASRR for Resident With Bipolar Disorder

Forest City, North Carolina Survey Completed on 04-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain a Level II PASRR evaluation for a resident admitted with an active diagnosis of bipolar disorder. A Level I PASRR was completed prior to admission, dated 03/20/18, and the resident was admitted with diagnoses including bipolar disorder. Review of the medical record showed no evidence that a Level II PASRR evaluation had ever been completed. The admission MDS documented an active diagnosis of bipolar disorder and indicated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. A subsequent quarterly MDS showed the resident was severely cognitively impaired, had no behaviors or signs of depression, but continued to have an active diagnosis of bipolar disorder and was receiving anticonvulsant and antidepressant medications daily.

Physician orders confirmed ongoing treatment with mirtazapine 15 mg by mouth at bedtime for depression and appetite, and Lamictal 25 mg by mouth daily as a mood stabilizer for bipolar disorder. The active care plan included a focus area for antidepressant medications with indications of depression and bipolar disorder, with a goal for the resident to remain free from side effects and interventions to administer medications as ordered and monitor for adverse effects. During interview, the Social Worker stated that because a Level I PASRR had already been completed prior to admission, she did not submit a referral for a Level II PASRR evaluation and was not aware that she was required to do so, despite knowing the resident had a bipolar disorder diagnosis. In a separate interview, the Administrator acknowledged the importance of completing Level II PASRR evaluations for residents who meet criteria so they can receive needed services.