Failure to Provide Timely Psychiatric Evaluation and Monitoring for Depression
Penalty
Summary
The facility failed to ensure that a resident exhibiting signs and symptoms of depression received necessary behavioral health care and services as ordered. The resident, who had a history of mental and behavioral disorders, was admitted with diagnoses including a history of trauma and a colostomy. Multiple assessments and care plans identified the resident as being at risk for depression, with documented symptoms such as loss of interest in activities, excessive sleepiness, and feelings of sadness. Orders for psychiatric evaluation were placed on three separate occasions, but there was no documentation that the resident was seen by a psychiatrist until several months after the initial order. Despite clear care plan interventions requiring psychiatric consultation and monitoring of depressive symptoms, the facility did not arrange for timely psychiatric evaluations or consistently monitor and document the resident's behavioral health status. Interviews with the resident revealed ongoing depressive symptoms, including a desire to sleep all day, loss of interest in activities, and emotional distress. The resident reported communicating these feelings to staff and requesting psychiatric support, but did not receive the ordered consults in a timely manner. Staff interviews indicated a lack of awareness and follow-through regarding outstanding psychiatric consult orders. The Social Services Director was unaware of previous consult orders and did not document pending psychiatric visits. The Assistant Director of Nursing and Director of Nursing confirmed that the psychiatric consults were not completed as ordered and that there was no behavior monitoring as outlined in the care plan. The facility's own policy required provision of necessary behavioral health services and timely referrals, but these were not carried out, resulting in the resident experiencing worsening depressive symptoms.