Failure to Provide Behavioral Health Services for Resident with Alcohol Abuse
Penalty
Summary
The facility failed to ensure that a resident with a primary diagnosis of alcoholic cirrhosis received necessary behavioral health care and services as required. The Social Services Director (SSD) did not refer the resident to a psychiatrist or psychologist for appropriate counseling and behavioral services for alcoholism, despite the resident's agreement to such services as documented in a behavioral contract. The behavioral contract, signed by the resident, specified that the resident would be referred to psychiatric services and would participate in periodic checks of personal belongings, but there was no evidence that these interventions were implemented. Additionally, the facility's licensed nurses and SSD did not develop or implement person-centered care plans addressing the resident's behavioral health needs related to substance abuse. The care plans in the resident's record focused on other diagnoses and general behaviors but did not include interventions or goals specific to managing alcohol abuse, psychiatric referrals, or participation in support programs such as Alcoholics Anonymous. Observations of the resident's behavior, including going outside near a liquor store, were documented, but no corresponding behavioral health interventions or referrals were made. Interviews with facility staff confirmed that no care plan or behavioral health services were provided to address the resident's substance abuse issues, despite multiple opportunities and documented agreements to do so. The facility's policies required individualized care plans and behavioral management, but these were not followed in this case, resulting in a lack of appropriate treatment and services for the resident's psychosocial adjustment difficulties.