Failure to Provide Necessary Behavioral Health Services and Medication Administration
Penalty
Summary
The facility failed to ensure that necessary behavioral health care and services were provided to a resident with a documented history of anxiety disorder, insomnia, and moderate depression. The resident had been assessed using the Minimum Data Set (MDS), which indicated moderate depression, and was noted by staff to have anxiety issues. The psychiatric nurse practitioner evaluated the resident and prescribed Ativan and Melatonin, with a recommendation for continued behavioral health services. However, review of the controlled drug sheets revealed that the evening dose of Ativan was not documented as removed from the supply on seven occasions in June, despite the resident expressing uncertainty about receiving the medication as ordered. No additional documentation was provided to confirm administration of the medication on those dates. Further review of the medical record showed that a psychologist had seen the resident and recommended follow-up psychotherapy within 2-3 weeks, stating that the resident's condition would deteriorate without continued treatment. Despite this, there was no documentation of any follow-up behavioral health visits by the psychologist, psychiatric nurse practitioner, or other behavioral health providers after the initial session. The absence of both medication administration documentation and timely behavioral health follow-up constituted a failure to provide necessary behavioral health care and services as required.