Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents who were identified as needing support for mood and behavior issues. For one resident with a history of depression, encephalopathy, and multiple suicide attempts, the facility did not implement recommended behavioral health interventions in a timely manner. Despite a PASRR Level II evaluation recommending ongoing psychiatric consultation and therapy, and provider orders for psychiatric and behavioral health evaluations, there was no documentation that these services were provided prior to a significant incident. The resident expressed ongoing depression and suicidal ideation, culminating in an event where they used a dinner knife to inflict injury and made stabbing motions toward their abdomen, requiring hospital transport. Behavioral health services were not initiated until 52 days after admission and 39 days after the suicidal gesture. Another resident with diagnoses including delusional disorder, major depressive disorder, and suicidal ideation was also not provided timely behavioral health services. The resident had a history of trauma and had recently been hospitalized for psychiatric reasons. The care plan indicated the need for weekly time to talk and a psychiatric consult, but there were no behavioral health evaluations or provider progress notes in the medical record. Although the resident signed a consent for behavioral health services, there was a delay in initiating these services, and no documentation was found to show that behavioral health interventions were provided as care planned. Staff interviews confirmed that behavioral health recommendations and care plans were not implemented in a timely manner for both residents. Staff acknowledged that behavioral health services, including medication management and therapy, were not provided as ordered or recommended, and that documentation of services offered or refused was lacking. The failure to provide timely and appropriate behavioral health care placed residents at risk for further decline in mental well-being and unmet care needs.