Failure to Address Mental Health and Psychosocial Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with mental disorders or psychosocial adjustment difficulties. For one resident with bipolar disorder, Parkinson's disease, and dementia, the care plan did not identify a history of suicide attempts or suicidal ideation, despite psychotherapy notes documenting such history and ongoing depressive symptoms. The resident expressed feelings of depression, loneliness, and discouragement, and made statements indicating possible suicidal ideation, but there was no evidence in the medical record that the facility was monitoring for signs and symptoms of depression or suicidal ideation. Staff interviews revealed a lack of awareness among CNAs, LPNs, and the social services director regarding the resident's mental health history and current symptoms, and the behavioral health notes were not regularly reviewed by the social services director. Another resident, with multiple sclerosis, bipolar disorder, and a recent major injury from a fall in the shower, expressed ongoing fear of taking showers after the incident. The resident reported this fear to several staff members and had not received a shower since the fall, instead receiving bed baths. Although the psychiatric evaluation noted the resident's fear, there was no follow-up assessment, evaluation, or referral to behavioral health services documented in the medical record. The care plan did not include interventions to address the resident's fear of showers, and staff who were aware of the concern did not report it to management or document it in the progress notes. Interviews with staff confirmed that the resident's fear was known to CNAs and LPNs, but this information was not communicated to the social services director or management. The social services director and primary care physician were unaware of the resident's expressed fear, and the regional clinical resource acknowledged a breakdown in communication and documentation. The lack of follow-up and failure to address the residents' mental health needs resulted in the facility not ensuring the highest practicable mental and psychosocial well-being for these residents.