Failure to Provide Timely Mental Health Treatment and Care Planning
Penalty
Summary
The facility failed to provide timely and appropriate services and treatment for a resident diagnosed with schizoaffective disorder, PTSD, and auditory hallucinations. The resident, who was alert and oriented, exhibited mood issues such as feeling down, trouble sleeping, fatigue, and negative self-perception. A psychiatric consultation recommended discontinuing the current antidepressant, Lexapro, and starting a new one, Zoloft, to address increased depressive and anxiety symptoms. However, as of April 9, 2025, the resident continued to receive Lexapro, and the recommendation for Zoloft had not been reviewed or ordered by the physician. Additionally, the facility did not develop a care plan with specific interventions to address the resident's PTSD diagnosis. The Director of Nursing acknowledged that the medication change recommendation was not implemented in a timely manner and that no care plan was developed for the PTSD diagnosis. This lack of timely action and care planning contributed to the deficiency in providing appropriate mental health services to the resident.
Plan Of Correction
Part 1. Resident # 27's care plan was immediately updated to include a newer diagnosis of PTSD. Social Services intervention to include a discussion with the resident to ensure psycho/social components of well being are addressed. The medication recommendations of changing Lexapro to Zoloft was updated in the resident's medication orders. Part 2. A 30-day look back was completed to review new admissions/re-admissions for PTSD diagnosis and any medication changes. Any new admissions/re-admissions will have a diagnosis and medication review during the morning clinical meeting. Current facility residents with a PTSD diagnosis were identified and reviewed. Care plans were assessed for completion. Part 3. Facility staff education completed on PTSD care planning requirements and updating recommended medication changes. Part 4. To prevent recurrence, the facility will audit the diagnosis and medication recommendations of new/re-admissions and appropriately care plan for the diagnosis of PTSD. Auditing will be completed weekly X 4 weeks, Bi-weekly X 4 weeks and monthly X 1 month. Results will be reviewed at QAPI. Part 5. Date of compliance is May 13, 2025.