Failure to Provide Consistent Behavioral Health Services
Penalty
Summary
The facility failed to ensure that a resident with significant behavioral health concerns received necessary and consistent behavioral health care services. The resident was admitted with diagnoses including unspecified dementia with psychotic disturbance, recurrent depressive disorders, and behavioral disturbances. Physician orders indicated a referral to a psychiatric provider for evaluation and treatment, and an initial psychotherapy assessment was completed, recommending ongoing psychotherapy one to four times per month to address symptoms such as agitation, anger, anxiety, psychosis, and aggressive or sexually inappropriate behavior. The resident's care plan also identified the need for psychiatric and psychological support, with approaches including psychiatric consultation and monitoring for behavioral issues. Despite these documented needs and recommendations, the resident received only one psychotherapy visit, with no further sessions documented after the initial assessment. During an interview, the administrator confirmed that the resident was not seen for additional psychotherapy visits and was unsure why services were discontinued. This lack of follow-up and ongoing behavioral health care represents a failure to provide the necessary services as outlined in the resident's care plan and physician orders.