Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to five out of twelve residents reviewed for behavioral health needs. Multiple residents with diagnoses such as Alzheimer's disease, major depressive disorder, dementia, anxiety, and psychotic disorders had not received timely psychiatric services. For example, one resident with severe cognitive impairment and a history of behavioral symptoms had not been seen by a psychiatric practitioner since August of the previous year, despite being prescribed psychotropic medications and having care plans that called for psychiatric consults as needed. Observations included residents exhibiting behaviors such as yelling out, crying, banging objects, and expressing confusion about their identity, with documentation showing significant lapses in psychiatric follow-up. Several residents had not received psychiatric services for extended periods, ranging from several months to over half a year, despite ongoing behavioral symptoms and care plans indicating the need for such services. Staff interviews confirmed that psychiatric services were not being provided as expected, with the DON and social worker acknowledging the absence of a current psychiatric provider and gaps in service delivery. The lack of psychiatric services was further corroborated by record reviews and staff interviews, which revealed that the facility did not have an active psychiatric group servicing the building for a period of time. This resulted in residents with significant behavioral health needs not receiving the necessary assessments or interventions, as outlined in their care plans and physician orders. The deficiency was identified through direct observation, interviews with staff, and review of medical records.