Failure to Implement Mental Health Recommendations for Resident with Depression
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and care in accordance with professional standards for a resident with depression and insomnia. The resident, who had moderately impaired cognition and moderate depression, was evaluated by a mental health provider who recommended starting an antidepressant, discontinuing the current sleep medication, conducting further psychological testing, and scheduling a follow-up. Despite these recommendations being documented in the resident's medical record, none were implemented into the plan of care for over three weeks following the evaluation. Interviews with facility staff revealed a lack of awareness regarding the mental health provider's recommendations. The LPN/Staff Development Coordinator was unaware that the resident had been seen by a mental health provider and did not know about the recommendations, citing a new process where mental health providers document directly into the medical record. The DON confirmed that the expectation was for nursing staff to review and implement such recommendations, but acknowledged that the recommendations for this resident were missed and not reviewed.