Failure to Communicate Behavioral Health Needs and Refer for Psychotherapy Services
Penalty
Summary
The facility failed to ensure that a resident with a history of insomnia, anxiety disorder, and major depressive disorder received necessary behavioral health care and services. The resident was observed and reported by staff and other residents to be yelling constantly, both day and night, which disrupted the sleep and well-being of nearby residents. Nursing staff documented these behaviors almost daily, and multiple staff members, including LPNs and the ADON, were aware of the ongoing disruptive behaviors. Despite this, there was no documented evidence that these behaviors were communicated to the psychiatric provider, nor was a psychiatric consult requested to address the resident's behavioral health needs. Interviews with staff revealed that non-pharmacological interventions, such as room changes and separating the resident from others, were attempted but proved ineffective. The psychiatric nurse practitioner confirmed only seeing the resident once for an unrelated issue and was not informed of the ongoing disruptive behaviors. The DON acknowledged awareness of the behaviors and their negative impact on other residents but admitted that no one had thought to refer the resident for a psychiatric consult, which could have allowed for further evaluation and intervention. Additionally, the facility failed to refer the resident for bedside psychotherapy services through their contracted Behavioral Health Services provider. The process required identification by the interdisciplinary team (IDT) and a referral for Medicaid approval, but the resident was neither identified nor referred, despite being classified as a Tier one resident due to disruptive behaviors. The facility's own policy required documentation of provided or attempted behavioral health services, but the medical record lacked evidence of such referrals or services for this resident.