Failure to Provide Behavioral Health Services for Resident with Depression
Penalty
Summary
A deficiency was identified when the facility failed to provide necessary behavioral health services to a resident who exhibited signs of depression following a significant life-changing event. The resident, a former school teacher who suffered a stroke resulting in right-sided weakness and the need for dialysis, expressed feelings of sadness, loss of independence, and uncertainty about recovery. During interviews and observations, the resident was noted to be tearful, reported not being approached about mental health services, and expressed interest in counseling, stating that it could help him mentally. Staff interviews confirmed awareness of the resident's depressive symptoms, with one staff member acknowledging that the resident seemed depressed and would likely benefit from mental health counseling. Despite this, there was no documentation of any follow-up or referral for behavioral health services, and the resident's participation in activities was minimal. The staff member who completed the PHQ-9 assessment upon admission recalled discussing mental health therapy with the resident but admitted there was no documentation of this conversation. Review of the resident's records showed a PHQ-9 score indicating moderate depression at admission, with no subsequent assessments completed before the survey. The care plan identified mood problems and included general interventions such as encouraging meaningful activities and monitoring mood, but there were no specific interventions or referrals for behavioral health services documented. The facility's policy requires person-centered behavioral health care, but the lack of documented interventions or referrals for the resident's depressive symptoms constituted a failure to provide necessary behavioral health services.