Failure to Provide Behavioral Health Services and Care Planning
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents with identified behavioral health needs. One resident, who was cognitively intact and had a history of end-stage kidney disease, diabetes, and alcohol dependence, was admitted with a Level II PASRR determination indicating a need for specialized behavioral health services. However, the resident's electronic medical record did not contain the required Psychiatric Evaluation Summary, and no behavioral health referrals or support were documented despite ongoing non-compliance with dialysis, medications, and dietary restrictions, as well as episodes of anger, irritability, and verbal abuse toward staff. The care plan lacked specific goals and interventions related to behavioral health needs, and staff interviews revealed that behavioral health services were not implemented due to the absence of the evaluation summary and changes in behavioral health providers. Another resident, with a history of stroke, major depressive disorder with psychotic symptoms, and delusional disorder, exhibited ongoing delusions, self-isolation, and distressing hallucinations. The resident's care plan included some general interventions but did not address their ongoing psychosocial needs or provide additional goals and interventions for their behavioral health concerns. Despite repeated indications for a Level II PASRR psychiatric evaluation, the assessment was not present in the resident's record, and there were no behavioral health referrals or provider progress notes for an extended period. The resident declined telehealth counseling sessions, and the facility did not have in-person behavioral health providers available, resulting in the resident not receiving counseling services after admission. Staff interviews confirmed that care plans were not consistently updated to reflect residents' behavioral health needs, and regular care plan review meetings had not occurred as intended. The lack of timely behavioral health assessments, absence of documented interventions, and failure to provide access to behavioral health services contributed to the deficiency, leaving residents without necessary support for their behavioral health conditions.