Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to identify and meet the behavioral health care needs of a resident, referred to as Resident R1, who was admitted with diagnoses of anxiety disorder, depression, and psychoactive substance abuse. Despite these conditions, the facility did not provide necessary psychiatric services or develop care plans addressing the resident's self-harming behavior, history of abuse, or substance abuse issues. Interviews with staff revealed that the resident exhibited behaviors such as picking at themselves until bleeding, yet there were no referrals to psychiatric services or communication with the resident's external drug and alcohol treatment facility. The facility also failed to maintain communication with the drug and alcohol treatment facility regarding the resident's leaves of absence (LOAs), lacking contact information and awareness of potential risks associated with the resident's past substance abuse history. The clinical record and care plans did not reflect any goals or objectives for managing the resident's behaviors or history of abuse. The Nursing Home Administrator confirmed these deficiencies, acknowledging the lack of communication and documentation necessary to support the resident's highest practicable social needs.
Plan Of Correction
1. Resident R1 met with the Psychologist and IDT team members. Resident R1 was care planned for identified behaviors of psycho social behaviors - making self-bleed. The IDT team confirmed with the resident that the individual whom the LOA's were with is not from a past abusive relationship. Due to resident residing at SNF, Resident R1 is guest dosing at a guest drug and alcohol clinic which does not require weekly psycho social updates, and is the responsibility of the facility to establish psycho social meetings at Resident R1's request. The facility attempted to contact Resident R1's home drug and alcohol clinic requesting a dialog and were denied at the request of Resident R1. 2. The Social Service department will audit to ensure Residents who receive methadone services, at a guest dosing drug and alcohol clinic, and have a hx of drug and alcohol abuse are asked if they wish to receive psychology services. 3. The Administrator will re in service the social service departments on the importance of ensuring individuals with psycho social behaviors and or hx of drug and alcohol abuse are asked if they want to receive psychology services. 4. The social service department will admissions for 2 weeks to ensure residents admitted with psycho social behaviors and or hx of drug and alcohol abuse are asked if they want to receive psychology services. Audits will be reviewed at QAPI committee to ensure continued compliance.