Failure to Provide Adequate Mental Health Assessment and Services
Penalty
Summary
A resident with diagnoses including Bipolar Disorder, Mood Disorder, Adjustment Disorder with mixed anxiety and depressed mood, and Cerebral Palsy was observed to be emotionally distressed, crying, and expressing concerns about not receiving adequate mental health care or psychological services. The resident reported a decline in mobility and stated they were not receiving any psychological support in the facility. Review of the resident's medical record confirmed the absence of prescribed antidepressants, mood stabilizers, or antipsychotic medications, despite the documented psychiatric diagnoses. The last psychological service provided was over six months prior, and there was no evidence of ongoing therapy or psychiatric follow-up. Progress notes and interviews revealed multiple behavioral incidents, including the resident calling 911 for non-emergent situations, verbal aggression, and refusal of medications and care. Despite these behaviors, there was no documentation of behavioral monitoring or interventions in the CNA records, and no referrals for psychiatric or psychological services were made after the last visit. The DON and Social Services Director confirmed the lack of psychotropic medications and therapy, and the Nurse Practitioner stated that no referral had been received for further psychiatric evaluation or treatment. Facility policy required ongoing assessment and care planning for residents with behavioral health needs, including documentation and referral for professional services as indicated. However, the facility failed to provide adequate assessment, treatment, and services to support the resident's mental and psychosocial well-being, as evidenced by the lack of medication management, therapy, and behavioral interventions for a resident with significant psychiatric diagnoses and documented behavioral concerns.