Failure to Provide Timely Behavioral Health Services for Resident with Trauma History
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of trauma and a diagnosis of mental disorder. Upon admission, the resident, who had Parkinson's disease, dementia, and a documented history of a traumatic and violent life event, exhibited behavioral symptoms such as verbal aggression and rejection of care. Despite facility policy requiring screening and referral for behavioral health services for residents with trauma histories or psychiatric needs, no referral to a psychiatrist or psychologist was made at or after admission. Additionally, the required Social Service assessment was not completed, remaining overdue for 46 days. The resident's care plan addressed the use of psychotropic medications for delirium and agitation but did not include a treatment plan for behavioral health services or address the resident's trauma history. Interviews confirmed that the Social Worker, responsible for making psychiatric referrals, did not initiate the necessary referral or assessments upon admission, despite the resident's documented history and ongoing behavioral symptoms. This resulted in a significant delay in the provision of behavioral health services for the resident.