PASRR SUMMARY OF FINDINGS EXAMPLE
Adult with PASRR mental health condition (“Ms. T”)
PASRR Summary of Findings
Diagnostic Impressions Axis I Primary: 295.70 Schizoaffective Disorder, Bipolar Type, Chronic Axis I Secondary: 300.00 Anxiety Disorder NOS Axis II Primary: 301.83 Borderline Personality Disorder Axis III: Significant for type II diabetes mellitus (DM II), neuropathy, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), hypertension (HTN), asthma, gastroesophageal reflux disease (GERD), coronary artery disease (CAD), osteoarthritis (OA), and morbid obesity. Surgeries include stent placement, left toe amputation, and a tonsillectomy. Current physician-­‐ordered medical treatments and nursing services include wound care, Heparin lock, physical therapy, and occupational therapy. Summary/History Ms. T is a 68 year old widow, residing at XXX [nursing facility], who was recently admitted to XXX [psychiatric hospital] on a physician emergency certification after she had been treated for extreme agitation while at the nursing home. Nursing home staff had described Ms. T as paranoid, anxious, and agitated. They reported that she had thrown herself on the floor, had thrown bowls and plates at staff, and threatened that she would kill herself by causing injury “any way that I can.” [Psychiatric hospital] notes indicate that treating professionals may suspect early indications of dementia, though no formal diagnosis has been made. Ms. T has had a diagnosis of schizoaffective disorder since early adulthood and has been hospitalized for psychiatric treatment many times. Ms. T has tried to commit suicide at least three times—each time by overdose. The last attempt was in 2008 when she took an overdose of lithium. She was found unconscious. The overdose caused lithium toxicity, and she was hospitalized in intensive care for several weeks and then transferred to XXX behavioral health unit for follow up mental health treatment. Ms. T has no children. Her husband, Sam, died four years ago by a self-­‐inflicted gunshot. She reports wanting to remain at XXX [the nursing facility]. Ms. T has been treated by a psychiatrist at the nursing home monthly. Before admission to the nursing home she was also receiving case management services by XXX mental health center. Ms. T says that she has best responded to Haldol and Depakote. She said that she has tried many treatments, but she can tolerate side effects of Haldol and Depakote and feels they are the most effective in controlling her symptoms. She talked at length about her realization that she stops taking medications when she feels she is stable. She is also able describe her cycles of regressing and improving and connects those to times when she stops taking medications. Over the past 30 days Ms. T has been increasingly tearful, anxious, and angry. The social worker described Ms. T as “inconsolable” at times. The nursing home social worker, XXX, says that Ms. T had begun threatening other residents, had tried to injure herself several times, and had been refusing both medications and treatments. Dr. XXX, Ms. T’s psychiatrist, ordered Geodon injections to be provided as needed. Those were not effective, and inpatient treatment was sought. 840 CRESCENT CENTRE DRIVE / SUITE 400 / FRANKLIN, TN 37067
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1 Ms. T connects this most recent episode to her the loss of her deceased husband. Their wedding anniversary and the anniversary of his death are less than one month apart and both occurred at this time of year. Ms. T says that she still blames herself for his suicide. She believes that their mutual struggles with depression made it difficult for both of them to maintain their marriage. She says that she had attempted suicide less than 30 days before Mr. T’s successful suicide. She seems to believe that her suicide attempt may have triggered her husband’s successful suicide. XXX, the nursing home social worker, says that Ms. T experiences ongoing struggles with depression and periods of unusual thinking even when her symptoms are controlled. Some of her “unusual” thoughts involve thinking that others are attempting to harm her. Sometimes, a touch on the arm and reassurance from staff that everything is okay helps Ms. T feel calmer. Ms. T. is very bonded with two staff at the facility—a social worker and one of the charge nurses, XX and XX. She says that those two will visit with her and those friendly chats seem to help Ms. T feel less anxious. Nursing home staff agrees that Ms. T greatly benefits from consistency in day to day caregivers and routines. Unique Personal Characteristics, Skills, and Talents Ms. T enjoys making crafts. She’s has taken a number of art classes through the years, preferring sculpting and painting. Ms. T reports that crafts ‘center me’ and reduce her anxiety. Ms. T is very sensitive. It matters to her how others feel about her. She develops strong bonds but with small groups of people. She likes structure and change makes her feel anxious. Specific Limitations and Needs Ms. T currently requires hands-­‐on assistance with dressing and bathing because she has difficulty reaching all parts of her body. She needs assistance to maintain her medication schedule for both medical and behavioral medications. She also requires physical assistance with some or all the physical steps of taking medications, including medication injections and assistance with blood sugar monitoring and insulin injections. Recommendations Ms. T struggles with very complex mental health issues that include symptoms of significant depression, guilt, and anxiety, which can lead to marked agitation and disruptive behaviors. Her mood and behavior can rapidly fluctuate. It would be beneficial for the nursing facility to work with [current psychiatric hospital], her psychiatrist, and/or with a mental health professional to create a care plan to help staff successfully respond to Ms. T when she is having difficulty. Gathering treatment and intervention information from prior mental health professionals who have worked with Ms. T may help identify successful strategies. It may be beneficial for staff to have a care conference with these professionals to discuss expectations of her stay, develop a plan for her care that takes into account her day to day behavioral health needs, that addresses improving her ability to manage frustration without escalating agitated behavior. She carries a considerable amount of guilt, believing that she is responsible for her husband’s death when, in fact, he also had a lifelong history of depression and had many suicide attempts before his ultimate death. Increased opportunities for formal and supportive therapy during the months preceding her wedding anniversary and the anniversary of her husband's death should be part of her plan. All staff should be educated about how to remain calm and assuring when responding to her when she is having difficulty managing her feelings. It is important that staff monitor her behavioral patterns, to help staff respond to situations before they escalate and to ensure her 840 CRESCENT CENTRE DRIVE / SUITE 400 / FRANKLIN, TN 37067
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2 psychiatrist has good information regarding medication effectiveness. Her mental health caregivers should be alerted if she poses a risk to self or others. As she can become overstimulated easily when she is agitated, it may be beneficial to have a designated quiet area for Ms. T. Changes in routine (i.e. late medications, new caregivers, etc.) tend to make her more anxious. It is quite important to maintain a regular routine, and to help her predict and prepare for changes. Whenever possible, it will help Ms. T to have staff who are familiar with her and with whom she has a bond. It will be helpful for staff to understand that her agitation and behaviors are not a personal attack, rather, they are an indication of the subjective distress she is feeling. Though her medical and behavioral conditions have limited her independence, Ms. T should be given support to make her own decisions, schedules, and plans as much as possible. It is important that staff support her self-­‐direction, guiding her to reflect on opportunities and consequences, so long as her choices do not put her, staff, or her peers at immediate risk of harm. She will benefit from support to improve her engagement in self-­‐care, self-­‐health management, and medication adherence. Ms. T may benefit from physical and occupational therapies to improve her strength and ability to complete activities of daily living independently. She should be referred for mental health counseling/psychotherapy and continue with her psychiatrist. She does benefit from socializing with peers, and may do well through interacting with fellow residents through craft and art activities. It is recommended that the NF social service worker follow up to clarify conservatorship status. Ms. T does not seek a community placement at this time. She would need intensive supervision and behavioral health supports to successfully transition to a community setting. She would require transportation services and significant IADL help. To successfully maintain her physical and behavioral health in the community, she would need close monitoring of her medical issues and adherence to medication regimens, case management, and intensive supports. At this time, she benefits from the structured environment, supervision, medical care and oversight, access to psychiatric care that she receives in the nursing facility. Specialized services to be provided by the state include (note each state determines which services are in the SS category and which are in the RS category. The categorization will vary state to state.): • Mechanism for the facility to develop a behavioral care plan with mental health professionals • Continued medication management by a psychiatrist; with an evaluation to consider pros/cons of returning to Haldol and Depakote, medications she believes have been most effective for her • Opportunity for grief counseling by a trained mental health specialist Rehabilitative services to be provided by the nursing facility include: • Support for improving her engagement in activities of daily living • Support for improving her self-­‐health care management • Support for improving her medication compliance and reporting of side effects • Occupational therapy evaluation • Supportive counseling from nursing facility staff, informed by behavioral care plan • Obtain psychiatric records from Ms. T’s case management provider to clarify treatment history and identify interventions that may be successful or effective for her • Supervision and safety plan • Consistent staff and routine, maximize consistency in schedule, staff 840 CRESCENT CENTRE DRIVE / SUITE 400 / FRANKLIN, TN 37067
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Engagement in art therapy, classes, activities 840 CRESCENT CENTRE DRIVE / SUITE 400 / FRANKLIN, TN 37067
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