Failure to Provide Ordered Behavioral Health Services Due to Missed Psychiatric Referral
Penalty
Summary
A deficiency occurred when a resident with a history of Parkinson's Disease, cognitive communication deficit, and dysarthria did not receive necessary behavioral health services as ordered. The resident exhibited signs of depression and moderate cognitive impairment, as indicated by a BIMS score of 12 and a mood interview score suggesting moderate anxiety or depression. Family members reported concerns about the resident's mental state, including depression, delirium, confusion, and possible hallucinations. These concerns were communicated to facility staff, and a nurse practitioner (NP) gave a verbal order for a psychiatric consultation after assessing the resident for depression and anxiety. Despite the NP's verbal order for a psychiatric consult, the order was not properly entered into the facility's system. The LPN who received the order documented it in the progress notes but failed to input it into the electronic system, which was necessary for the referral to be processed. The social worker, who would typically arrange for such services, was not made aware of the order and did not receive any complaints or information regarding the resident's need for psychiatric services. As a result, no psychiatric consultation was scheduled or provided, and there was no follow-up documented regarding the order. Interviews with facility staff, including the administrator, DON, social worker, and LPN, revealed a breakdown in communication and process. The staff acknowledged that the verbal order was missed and that the resident did not receive the psychiatric services as intended. The facility's policy required collaboration between nursing and social services to arrange ordered services and documentation of referrals, but this process was not followed in this instance, resulting in the resident not receiving the necessary behavioral health care.