Failure to Implement Psychiatric Medication Recommendations for Resident with Mental Health Diagnoses
Penalty
Summary
A resident with diagnoses including schizoaffective disorder, anxiety disorder, and PTSD was admitted to the facility and later reported increased anxiety and sleep disturbances. The resident underwent a psychiatric consultation, which resulted in recommendations to adjust current medications and initiate a new medication to address nightmares and anxiety. The psychiatric consultation document containing these recommendations was sent to the facility, but there was no evidence that the physician was made aware of the recommendations or that the medication changes were implemented. Interviews with the resident revealed ongoing symptoms and repeated requests for medication changes, which were not addressed. Staff interviews indicated a lack of communication and follow-through regarding the psychiatric recommendations, with the responsible nurse not reviewing or acting on the recommendations and the DON acknowledging that the recommendations had not been reviewed or implemented by the physician, even eight days after the consultation. This failure resulted in the resident not receiving necessary behavioral health care and services as required.