Failure to Notify State Mental Health Authority of Significant Mental Status Change
Summary
The facility failed to ensure that the state mental health authority was notified when a resident with bipolar disorder had a significant change in mental condition. Resident #37 was admitted with diagnoses including atherosclerotic heart disease, bipolar disorder, and colostomy status. A Level 1 PASARR completed in February 2025 did not include the bipolar diagnosis, and an April 2025 Level 1 PASARR included bipolar disorder but was followed by an email from the state mental health authority stating the resident met the terminal illness exemption and did not require a Level 2 PASARR because of hospice status and a life expectancy of less than 6 months. The resident later had a hospice discharge-transfer summary showing hospice services ended on July 18, 2025 due to extended prognosis. After hospice discharge, nursing documentation on August 3, 2025 described medication refusal, tearfulness, refusal of some meals, and crying while asking why staff treated her that way, with staff noting another person was present because the resident made false accusations. The care plan was updated on August 4, 2025 to address behavior problems related to bipolar disorder, resistive to care, and false accusations. A significant change of condition MDS later documented active bipolar disorder, no psychological services, and no hospice care. On August 13, 2025, multiple medication administration notes documented continued refusal of medications, with the resident stating, "If the Holy Spirit wants to heal me he will or I will go home." The primary care physician and psychological services were notified, and a psychiatric note on the same date stated a urinary tract infection could be contributing to the recent behavior change and delusional thinking. Another psychiatric note on August 22, 2025 recommended a mood stabilizer, which the resident declined. The clinical record contained no evidence of an updated Level 1 PASARR after hospice discharge or after the significant change in mental condition, and staff interviews confirmed that the PASARR should have been resubmitted for a change of condition determination.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to notify the State Mental Health Authority of a significant change in status for a resident previously identified with serious mental illness. The resident had anxiety, dialysis dependence, and escalating behavioral concerns documented in the care plan and MDS, including verbal aggression, refusal of care, social withdrawal, and self-mutilating behaviors. The DON acknowledged the resident’s behaviors had increased and stated a significant change PASARR probably should have been completed.
Failure to notify the state mental health authority of significant change PASARRs for two residents with serious mental illness. One resident with schizoaffective disorder had escalating behaviors and physical aggression that led to inpatient psych hospitalization, and another resident with schizophrenia and anxiety had increased delusions, aggression, and threats that led to transfer to a psych hospital. In both cases, the record showed no documentation of a significant change PASARR or notification to the state mental health authority.
A resident with a Level II PASRR and diagnoses of schizophrenia and major depressive disorder had escalating behavioral issues, including threats toward other residents, bullying, and cutting up a roommate's shirt, which led to an inpatient psychiatric admission. Social Services confirmed this was a significant change in status but did not submit the required status change referral to notify the state mental health authority, and the DON stated she was not familiar with the PASRR process.
Failure to submit a Level II PASRR reevaluation after a resident with a prior Level II PASRR had a significant change in condition. The resident had anxiety, bipolar disorder, depression, and PTSD, and the MDS showed serious mental illness and/or ID-related conditions with ongoing psychotropic meds. The MDS coordinator confirmed the reevaluation request was not submitted, and the Administrator stated such requests are required when a resident has a significant change.
A resident with no cognitive impairment developed loose stools, rectal pain, weakness, and refusal to eat or drink because food worsened her symptoms. Nursing notes showed the resident’s complaints persisted for several days before the provider was notified, despite repeated reports of internal rectal pain, burning, and inability to sit up. The resident and family stated staff mainly offered Imodium and did not respond to her concerns, and the resident was later sent to the ER after the NP noted buttock inflammation and concern for cellulitis.
Failure to notify the state mental health authority after significant mental health changes for two residents. One resident with CHF, malnutrition, and muscle weakness later developed depressed mood, disorganized and tangential thinking, and assaulted a roommate; another resident with metabolic encephalopathy and cognitive communication deficit was later diagnosed with adjustment disorder with anxiety. Neither record documented the required PASRR-related notification, and the MDS nurse and nursing staff did not notify the Medical Records Director of the changes.
Failure to Report Significant Change in Mental Health Status
Penalty
Summary
The facility failed to notify the State Mental Health Authority of a significant change in status for one resident who had previously been identified as having serious mental illness. The resident was admitted with diagnoses including end-stage renal disease, dialysis dependence, and an anxiety disorder. Review of the PASARR Level 1 showed serious mental illness and psychotropic use without symptomology, and the PASARR Level II found the resident appropriate for nursing home placement and not in need of specialized or psychiatric rehabilitative services. The resident’s care plan documented multiple behavioral concerns over time, including agitation, profanity toward staff, picking at skin and scabs, social withdrawal, refusing to talk to certain staff, and episodes of verbal aggression related to frustration with family. The annual MDS documented that the resident had little interest in doing anything, felt down, depressed, or hopeless almost daily, had rejection of care for one to three days out of seven, and that these behaviors had worsened since the prior assessment. The assessment did not document delusions or hallucinations. During interviews, the DON stated the resident had made comments about other dependent residents, refused medication, declined behavioral health, and at times refused insulin and dialysis, with a recent progress note describing self-mutilating behaviors. The SSD stated the resident’s acting out seemed to be getting worse. The Administrator stated the resident was aggressive and that the team had discussed him in QAPI, tried counseling, and tried family involvement. In a follow-up interview, the DON acknowledged that the resident’s verbal behaviors, rejection of care, and self-mutilating behaviors had increased and stated that a significant change PASARR probably should have been completed.
Failure to Notify State Mental Health Authority of Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority when two residents with serious mental illness had significant changes in condition. Resident #2 was admitted with schizoaffective disorder, bipolar type, and had a PASARR indicating serious mental illness. After a recent escalation in behaviors and physical aggression, the resident was referred for an inpatient psychiatric evaluation, accepted for psychiatric treatment, and later returned from hospitalization. The medical record contained no documentation that the facility completed a significant change PASARR or notified the state mental health authority of the psychiatric hospitalization or the change in mental health condition. Resident #37 was admitted with paranoid schizophrenia and anxiety disorder, and the PASARR indicated serious mental illness. After increased delusions and aggression, including verbal aggression, yelling, cursing, and threats to harm others, the resident’s mental health provider was contacted and the resident was transferred to a psychiatric hospital for evaluation with police assistance. The resident later returned from the psychiatric hospital, but the record contained no documentation that the facility completed a significant change PASARR or notified the state mental health authority of the psychiatric hospitalization or the change in mental health condition.
Failure to Notify State Mental Health Authority After Significant Change in Status
Penalty
Summary
The facility failed to notify the State Mental Health Authority of a resident with a significant change in status after an inpatient psychiatric admission for one of four PASRR records reviewed. Resident #6 had a Level II PASRR with diagnoses of schizophrenia and major depressive disorder, and the facility policy required that any Level II resident who experiences a significant change in status be referred promptly to the state mental health or intellectual disability authority for additional resident review, including residents with increased behavioral, psychiatric, or mood-related symptoms. Record review and interviews showed that Resident #6 had escalating aggressive and behavioral issues, including threatening violence toward multiple residents, bullying residents, and cutting up another resident's shirt. The resident reported being transferred to an inpatient psychiatric facility twice since admission, with the most recent transfer occurring after cutting up a roommate's shirt with scissors to make a pillowcase. Social Services confirmed the resident's schizophrenia, the inpatient psychiatric stay, and that the behavior constituted a significant change in status, but acknowledged that no status change referral was submitted to notify the state mental health authority. The DON also confirmed the resident experienced a significant change in status and stated she did not have knowledge related to the PASRR process.
Failure to Submit PASRR Reevaluation After Significant Change
Penalty
Summary
The facility failed to submit a request for a Level II PASRR reevaluation after a resident with a prior Level II PASRR had a significant change in physical or mental status. Resident #90 was admitted with diagnoses including anxiety disorder, bipolar disorder, depression, and PTSD. A PASRR Level II Determination Letter dated 12/08/23 showed the resident had a Level II PASRR with no effective date and that nursing facility placement was appropriate. A significant change MDS assessment dated [DATE] identified Resident #90 as having a serious mental illness and/or intellectual disability or other related conditions, with active psychiatric and mood disorder diagnoses including anxiety disorder, depression, bipolar disorder, and PTSD. The resident also received antipsychotic, antidepressant, and antianxiety medications during the assessment period. Review of the medical record found no evidence that a Level II PASRR reevaluation request was submitted after the significant change assessment. During interviews, the MDS Coordinator confirmed she was responsible for submitting these requests and stated she did not submit one for this resident, describing it as an oversight. The Administrator stated that Level II PASRR reevaluation requests should be made when a resident has a significant change in condition per regulatory guidelines.
Failure to Timely Notify Provider of Resident’s Significant Change in Condition
Penalty
Summary
The facility failed to notify the medical provider of a significant change in condition for one resident who reported loose stools, rectal pain, weakness, and not eating or drinking because it hurt her intestine and rectum. The resident’s record showed she had no cognitive impairment, used a walker independently, and was continent of bowel and bladder. Her care plan identified pain, decreased strength, assistance with hygiene, and fall risk. She also had a history that later included congestive heart failure, failure to thrive, anemia, swollen legs, chronic kidney disease, and diabetes. The resident told nursing staff she had loose stool for several days, but provider notification did not occur until three days later. On the first documented night, the nurse offered Imodium, which the resident declined, and noted the provider would be updated the next day; however, there were no progress notes for that day. Subsequent nursing notes documented ongoing loose stool, rectal burning and pain, weakness, shortness of breath, and refusal to eat because food worsened the stool and pain. The resident stated staff were only offering Imodium and were not helping her, and family reported she had been sick since the prior Friday and could not eat because food passed right through her. The provider was first updated after the resident had already experienced several days of symptoms. The NP later documented buttock pain, inability to sit up, localized soft tissue inflammation, and concern for cellulitis, with instructions to give Imodium, encourage food and fluids, and send the resident to the ER if she did not improve. The resident was ultimately sent to the hospital, where she reported a rectal wound infection that had spread to her blood. The facility policy required staff to assess changes in condition, report findings to the supervisor or DON if the resident refused examination, update the provider, contact family, and document findings, interventions, and orders.
Failure to Notify State Mental Health Authority After Significant Mental Health Changes
Penalty
Summary
The facility failed to notify the state mental health authority for two sampled residents who had significant changes in mental health status. One resident was admitted with CHF, malnutrition, and muscle weakness, had a PASRR Level 1 screening showing no need for a Level 2 screening due to negative SMI, later developed mood symptoms and was diagnosed with adjustment disorder with depressed mood, then showed disorganized and tangential thought processes and became upset and physically attacked his roommate after a war movie was being watched in the shared room. The medical record did not document notification to the state mental health authority regarding this change in mental health status. A second resident was admitted with metabolic encephalopathy and cognitive communication deficit, had a PASRR Level 1 screening showing no need for a Level 2 screening due to negative SMI, and was later diagnosed with adjustment disorder with anxiety. The record did not document notification to the state mental health authority regarding this significant change in mental health status. During interview, the Medical Records Director stated she was responsible for ensuring PASRR processes were completed and that the MDS nurse and nursing staff were responsible for notifying her when residents experienced significant mental health changes requiring renewed PASRR referral, but she had not received notification regarding either resident.
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