Failure to Refer Resident with Behavioral Issues for Psychiatric Evaluation
Penalty
Summary
The facility failed to ensure proper communication and referral for behavioral health services for a resident with a history of Major Depressive Disorder and documented behavioral manifestations. Despite multiple documented incidents of the resident attempting to elope and displaying aggressive behaviors towards staff and other residents, there was no evidence that these behaviors were communicated to the appropriate staff or that a referral to psychiatry was made, as required by facility policy. The resident's care plan did not reflect these behavioral issues, and social services notes lacked documentation of referrals or communication with the charge nurse regarding the incidents. Interviews with facility staff, including the Social Services Director and Assistant Director of Nursing, confirmed that the process for referring residents with behavioral issues to psychiatric evaluation was not followed. The Social Services Director was unaware of the resident's behaviors in February and acknowledged the absence of a paper trail or intervention following the early identification of behavioral issues. The facility's policy required close monitoring, assessment, and interdisciplinary communication for residents exhibiting behavioral difficulties, but these steps were not documented or implemented for this resident.