Failure to Arrange Psychologist Consultation for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), major depressive disorder, and anxiety received a psychologist consultation as requested by the resident and ordered by the physician. The resident's care plan included interventions such as medication management, encouragement to verbalize feelings, and a psychology consultation as needed. Despite a standing order for a psychologist consult and the resident's direct request to the Social Services Director (SSD), no appointment was made, and the request was not documented. The SSD assumed that the standing order was sufficient and did not follow up or arrange the necessary consultation. Interviews revealed that the resident specifically asked to see a psychologist, but the SSD did not act on this request or document the conversation. The Director of Nursing (DON) confirmed that the SSD should have scheduled the appointment and documented the resident's request. Facility policy and the SSD job description both require the provision and documentation of medically related social services, including arranging for mental health counseling when needed. This lapse resulted in the resident not receiving the proper assessment and necessary treatment for his PTSD.