Failure to Provide Behavioral Health Services and Medication Review Follow-Up
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with diagnoses including attention-deficit hyperactivity disorder and bipolar disorder. A monthly medication review recommended a psychiatric evaluation of the resident's medications as a contributing factor to falls, but this review was neither signed by the physician nor acknowledged by facility staff. Additionally, there was a lack of documentation regarding the initiation or follow-up of mental health services for the resident, with only sporadic references to referrals and no evidence of consistent behavioral health interventions. Interviews with facility staff revealed that there were limited resources for mental health services, and several residents were waiting to start services with a newly contracted mental health provider. Staff also indicated that previous attempts to connect residents with local mental health organizations were hindered by logistical challenges and excessive wait times. The social services department and medical director were involved in discussing and reviewing behavioral health needs, but there was no documentation that these services were provided or that recommendations were acted upon for the resident in question.