Failure to Provide Medically Related Social Services for Residents with Mental Health Needs
Penalty
Summary
The facility failed to provide medically related social services to four residents with significant mental health diagnoses, including schizophrenia, major depressive disorder, mood disorder, anxiety disorder, and seizure disorder. Documentation review revealed that these residents did not receive consistent psychosocial support or follow-up for their mental health needs, despite recommendations for regular therapy and psychiatric follow-up. For example, one resident with paranoid schizophrenia and major depressive disorder had no current psychosocial support documented, while another with multiple mental health diagnoses had no consistent psychosocial reviews or follow-up after a physician appointment. Another resident was recommended for weekly psychiatric visits but had no documented interventions following behavioral incidents, and a fourth resident had no clinical documentation of psychosocial support after a recommendation for weekly therapy. Interviews with the facility's social worker confirmed that there was no established process for identifying residents in need of additional psychiatric social services, nor was there a maintained list of residents requiring regular psychosocial support. The social worker acknowledged that while a personal list was kept, it was not reflected in the clinical records of the affected residents and was not provided upon request. This lack of documentation and process resulted in the failure to provide necessary medically related social services as required by facility policy and regulatory standards.