Failure to Document and Provide Interventions for Resident with Depression and Grief
Penalty
Summary
A deficiency occurred when the facility failed to provide and document appropriate interventions and services for a resident diagnosed with major depressive disorder who had recently experienced the loss of a spouse. Observations and interviews revealed that the resident displayed signs of depression, such as an expressionless affect, lack of engagement, and tearfulness when discussing his wife's death. Although the resident was previously on an anti-depressant, it had been discontinued, and there was no evidence that counseling or other supportive interventions were offered or documented following his spouse's passing. Interviews with the social services designee (SSD), nursing staff, and the director of nursing indicated uncertainty and lack of documentation regarding any offers of counseling services, discussions about resuming anti-depressant medication, or other interventions to address the resident's ongoing grief and depressive symptoms. The SSD and other staff members stated that such conversations may have occurred and that the resident and his family may have declined services, but no documentation was available to support these claims. Additionally, the SSD was not a licensed social worker and required oversight, but there was no documentation of what was reviewed or discussed during oversight meetings with the licensed social worker. Review of the resident's medical record, care plan, and physician notes confirmed the absence of documented interventions or follow-up regarding the resident's depression and grief. The care plan had not been updated to reflect new interventions after the spouse's death, and interdisciplinary team meetings did not document any offers of counseling or medication review. The facility's policy required documentation of social work interventions, but no such documentation was found to support that appropriate psychosocial care was provided.