Failure to Provide Mental Health Referral and Treatment
Penalty
Summary
A deficiency was identified when a resident with diagnoses of post-traumatic stress disorder, anxiety disorder, and depression did not receive appropriate mental health referral and treatment. The resident's medical record showed significant mood and behavioral symptoms, including a high severity mood score and frequent verbal behaviors towards others. The care plan acknowledged the resident's potential for verbal behaviors and included interventions such as evaluating the need for psychiatric or behavioral health consultation. The resident had signed an authorization for behavioral health services with Meditelecare, and physician orders included obtaining psychiatric consults as needed. Despite these documented needs and authorizations, there was no evidence in the medical record of any screenings, evaluations, or progress notes from Meditelecare or any other behavioral health provider. Upon repeated requests, the Director of Nursing confirmed that there were no such documents available, indicating that the resident did not receive the mental health services that were indicated by their diagnoses and care plan.