Failure to Provide Behavioral Health Services for Resident with Behavioral Symptoms
Penalty
Summary
A resident with diagnoses including unspecified psychosis, end-stage renal disease, dependence on renal dialysis, restlessness and agitation, unspecified dementia, and mood disorder exhibited behavioral symptoms, including physical behaviors toward others and other behavior symptoms as documented in the clinical record. On one occasion, the resident was observed in another resident's room with hands on the other resident's neck and head, prompting notification of the physician, DON, administrator, and responsible parties. The psychiatric nurse practitioner (NP) recommended an emergency behavioral health consult and suggested transfer to a behavioral health facility, but this was not possible due to the resident's dialysis needs. Despite the recommendation, there was no documentation of mental health services provided to the resident for the last four months. Interviews with facility staff confirmed that the resident had not been referred for behavioral health services as recommended by the NP. The social worker stated that the resident was monitored but had not been referred, and the RN explained that the resident was unavailable for behavioral health services on the days the provider was present due to dialysis appointments. The DON and administrator both acknowledged that arrangements should have been made for the resident to receive behavioral health services on a different day, but this did not occur.