Failure to Identify and Address Behavioral Health Needs
Penalty
Summary
The facility failed to identify and address the mental and psychosocial health needs of two residents with behavioral-emotional health concerns. For one resident with depression, anxiety disorder, and cognitive communication deficit, assessments indicated moderately severe depression, social isolation, and a request for behavioral health services (BHS). Despite documentation of a high PHQ-9 score and a referral being indicated, there was no evidence in the clinical record that a BHS referral was made or that services were provided. Staff interviews revealed a lack of awareness and follow-through regarding the referral process, with no documentation of the referral in the resident's chart. For another long-term resident with severe cognitive impairment and a diagnosis of depression, the provider documented a referral for BHS, but there was no evidence in the record that the resident refused the service or that the referral was completed. The resident's assessment indicated depression and ongoing use of medication, but the required behavioral health interventions were not documented. The lack of timely and documented referrals and follow-up for behavioral health services contributed to the deficiency.