Failure to Provide Timely and Ongoing Mental Health Services
Penalty
Summary
The facility failed to provide mental health services in accordance with professional standards for a resident admitted with multiple mental health diagnoses, including PTSD, generalized anxiety disorder, bipolar disorder, major depressive disorder, and a history of substance abuse and suicidal behavior. Upon admission, the resident's social services assessment identified significant mental health needs, but a timely referral for mental health services was not made. Although facility protocol required automatic referral for residents with mental health diagnoses, this was not followed, and the resident was not referred for mental health services until several weeks after admission. Additionally, the facility did not ensure that mental health services were provided on a continual basis. After the initial psychiatric evaluation and two follow-up visits, there were no further mental health encounters documented for the resident, despite ongoing use of antipsychotic and antidepressant medications. Staff interviews confirmed that the resident should have been seen monthly by the mental health nurse practitioner, but this did not occur after the last documented visit.