Failure to Provide Behavioral Health Services and Follow-Up for Resident with Mental Health Needs
Penalty
Summary
The facility failed to provide appropriate behavioral health treatment and services to a resident with a history of bipolar disorder and developmental delay. The resident had a psychiatric consult via telehealth, which included recommendations for a neuropsychology referral and continued assessment of psychotropic medications. However, these recommendations were not communicated to the medical doctor or licensed nursing staff, and no evidence was found that the orders were transcribed or acted upon. The medical doctor was unaware of the psychiatric consult and its recommendations, and the social services department did not arrange for the recommended neuropsychology referral. The resident exhibited escalating behavioral issues, including anger, verbal aggression, medication refusal, and social withdrawal. Staff interviews confirmed that the resident was refusing care and medications, had become more aggressive, and was isolated in a private room due to his behaviors. Despite a physician's order for a psychiatric evaluation and adjustment of treatment, there was no documentation that the evaluation occurred as ordered, and staff were unclear about who was responsible for scheduling and following up on mental health consults. The telehealth psychiatric service was not effectively coordinated, and there was a lack of communication between nursing, social services, and the medical provider. Facility policies indicated that social services should arrange for needed mental and psychosocial counseling and that behavioral health services should be person-centered and coordinated. However, interviews with staff revealed confusion about roles and responsibilities, with both nursing and social services staff unaware of the resident's psychiatric consult orders or the need for follow-up. As a result, the resident's psychosocial needs were not met, and recommended mental health interventions were not provided.