Failure to Provide Required Behavioral Health Services After Psychiatric Recommendation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with multiple mental health diagnoses, including PTSD, schizoaffective disorder, bipolar disorder, borderline personality disorder, depressive disorder, and generalized anxiety disorder. The resident had recently been admitted to the hospital for suicidal ideation and exacerbation of bipolar symptoms, and upon return to the facility, there were documented recommendations for ongoing psychiatric management and follow-up. Despite a physician's order for psychiatric consultation and treatment, as well as care plan interventions to refer the resident to psychiatric services, there was no evidence in the clinical record that the resident had been seen by the facility's consultant psychiatric services. Interviews with facility staff confirmed that the resident should have been referred for behavioral health follow-up but was not. The resident also reported not having seen a psychiatric specialist since admission. The facility's own policy required staff to notify consultants and document responses in the medical record, but this process was not followed for this resident, resulting in a lack of necessary behavioral health services after clear recommendations and orders were made.