Failure to Provide Behavioral Health Care After Traumatic Incident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident after the resident witnessed the death of another resident in their shared room, following an incident involving illicit drug use. The resident who witnessed the event had a documented history of major depressive disorder, unspecified mood disorder, opioid and alcohol abuse, substance-induced mood disorder, schizoaffective disorder, and anxiety disorder. The resident was on a methadone program and had interventions in place for substance abuse, including opportunities to vent feelings and random toxicology screenings. After the incident, the resident reported increased anxiety and depression and stated that no one from the facility spoke to them regarding the death. The social worker made one attempt to speak with the resident, who refused to discuss the incident, but did not make further attempts or document the refusal. The Director of Nursing was unaware of the social worker's visit and stated that the incident should have been discussed in an interdisciplinary care plan meeting and documented. The Licensed Nursing Home Administrator also indicated that the social worker should have documented the interaction in the progress notes. A review of the resident's medical record showed that the physician and psychiatric nurse practitioner saw the resident after the incident, but there was no documentation of psychosocial support being provided. The facility's policies did not include procedures related to psychosocial support following such incidents, and the social worker's job description required working directly with residents experiencing emotional difficulties. The lack of follow-up and documentation resulted in the failure to provide necessary behavioral health care and services to the resident.