Failure to Provide Behavioral Health Services and Timely Care Planning
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident diagnosed with vascular dementia, hemiplegia, anxiety disorder, and depressive disorder. Upon admission, the resident was moderately cognitively impaired and expressed interest in counseling or therapy services, but reported not being offered any such services during their stay. Review of the clinical record showed that a care plan addressing depression and anxiety was not initiated until approximately nine months after admission. Prior to this, there was no evidence of a care plan targeting these behavioral health needs. Additionally, documentation indicated that after an initial behavioral health assessment and recommendation for psychotherapy 1-2 times per month, there was no record of the resident receiving any psychotherapy services following the initial visit. Interviews with facility staff, including the Social Worker and DON, confirmed uncertainty regarding the implementation of a care plan for depression and anxiety prior to the late initiation and acknowledged that the resident had not received the recommended psychotherapy services, with no explanation provided by the behavioral health agency.