Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to two residents who were identified as needing psychiatric evaluation and treatment. Both residents had physician orders for psychiatric consultation following incidents involving behavioral or psychosocial concerns. Despite these orders, there was no evidence in the residents' records of any psychiatric consultation being scheduled, completed, or followed up on. One resident, a male with diagnoses including dementia, cognitive communication deficit, and metabolic encephalopathy, exhibited combative and aggressive behaviors, including an incident where he was physically aggressive toward another resident and a nurse. His care plan included an intervention for psychiatric evaluation and treatment as ordered by the physician. However, the order for psychiatric services was not acted upon, and no documentation of a psychiatric evaluation was found in his record. The second resident, also a male with Alzheimer's disease and cognitive communication deficit, was involved in an altercation where he was kicked by another resident. His care plan addressed potential psychosocial well-being problems and included an order for psychiatric evaluation and treatment. Similar to the first case, there was no documentation of a psychiatric consultation or follow-up. Interviews with facility staff, including the DON and Administrator, confirmed that the social worker responsible for making the referrals did not follow through with the orders, and no psychiatric services were provided as required.