Failure to Assess and Document Behavioral Health Needs in Facility Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to accurately determine the resources necessary to care for its resident population, specifically neglecting to identify and evaluate residents with psychiatric and/or mood disorder diagnoses. Record review showed that the facility assessment did not list any residents with such diagnoses, and staffing was marked as adequate for dementia and mental health conditions, with behavioral health services noted as not applicable. However, staff interviews confirmed that 37 residents residing in the facility at the time had psychiatric and/or mood disorder diagnoses, indicating a significant discrepancy between the documented assessment and the actual needs of the resident population.