Failure to Implement Timely Behavioral Health Recommendations
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with major depressive disorder, PTSD, and visual hallucinations. The resident was assessed as cognitively intact and was experiencing persistent and distressing hallucinations. A psychiatric evaluation recommended starting Abilify 2.5 mg daily to address these symptoms, and this recommendation was discussed with the resident, who agreed to the plan. However, a review of physician orders and medication administration records showed that Abilify was not initiated as recommended. Subsequent psychiatric follow-up noted that the resident continued to experience distressing hallucinations and had not started the recommended medication. The psychiatric provider reiterated the recommendation to initiate Abilify, but there was no documentation that the nurse practitioner or physician was notified of this ongoing need. Progress notes from the nurse practitioner did not address the lack of initiation of Abilify, and the medication was not started until 23 days after the initial recommendation. Interviews with nursing staff and the nurse practitioner revealed a breakdown in communication and follow-through regarding the psychiatric recommendations. The nurse practitioner was under the impression that the medication had been started and stated she would have acted if notified otherwise. The Director of Nurses confirmed that the process for implementing consultant recommendations was not followed, and the necessary notifications and order entries were not completed in a timely manner.