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.
A resident with an initial PASRR Level 1 showing no serious mental illness later developed new diagnoses of depression and anxiety, with psych eval findings and an order for escitalopram. The chart had no evidence that MDS staff completed and submitted a new Level 1 PASRR after the significant change in mental condition, and both the MDSA and DON confirmed this should have been done.
The facility failed to resubmit PASRRs for two residents after changes in their mental health conditions. One resident, admitted with paranoid schizophrenia, later received new diagnoses of anxiety, PTSD, and unspecified psychosis and was started on Zyprexa, but no repeat PASRR was completed. Another resident, admitted with anxiety and unspecified psychosis, later had a care plan update for psychosocial needs related to anxiety and was started on Trazadone, but no new PASRR was initiated. The MDSC acknowledged the repeat PASRRs were not done after the residents’ mental condition changes.
Failure to Update PASARR After Significant Change: A resident with dementia, schizophrenia, and hospice services had a significant change when admitted to hospice, but the MDS Nurse did not find or complete a new level 1 PASARR screening. The resident was observed restless and unable to answer questions appropriately, and both the MDS Nurse and DON acknowledged that a new PASARR assessment should have been completed for the hospice-related change.
Failure to notify the state mental health authority after a resident with dementia, MDD, psychosis, and anxiety showed a decline in mental status and behavior. Records showed depression, withdrawal, poor intake, medication refusal, weight loss, and worsening involuntary movements, while the PASRR process had not been updated to reflect the resident’s changed condition.
PASRR Not Updated After New Schizophrenia Diagnosis: A resident’s PASRR remained a negative Level I screening even after a psychiatry note documented depression, anxiety, visual hallucinations, and a diagnosis of schizophrenia. The MDS later listed schizophrenia as an active diagnosis, and the DON stated the PASRR should have been updated when the new diagnosis was received so the resident could be evaluated for appropriate care and services.
A resident with multiple diagnoses and moderate cognitive impairment had abnormal urinalysis results indicating possible infection, but the facility failed to notify the physician or responsible party and did not document the change in condition as required by policy.
Nursing staff did not promptly recognize or report a significant change in condition for a resident with multiple complex diagnoses, resulting in delayed acute care treatment and eventual hospital transfer. The resident experienced a notably low blood pressure, and despite a physician order to push fluids, there was no timely escalation or evaluation. The DON confirmed that facility policy was not followed, leading to the resident's extended hospital admission and dissatisfaction with care.
The facility did not notify the appropriate authorities when a resident with MD or ID services experienced a significant change in condition, as required.
A resident with a history of mental health conditions was newly diagnosed with Paranoid Schizophrenia, but the facility did not notify the State Mental Health or Intellectual Disability authorities or complete a required PASARR. Staff interviews confirmed that the MDS Coordinator was responsible for these actions, but they were not carried out, and facility policy was not followed.
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