Failure to Provide Behavioral Health Services Following Resident Request
Penalty
Summary
Resident 264, who had diagnoses of anxiety and depression, was admitted to the facility and was identified as being at risk for changes in mood or behavior due to their medical conditions. The resident's care plan included interventions for staff to provide a psychological evaluation consult as indicated. Documentation showed that the resident requested a referral for a psychological evaluation, but the status of this referral remained pending with no documented follow-up. Multiple progress notes and interviews indicated that the resident continued to express emotional distress, including tearfulness, sadness, and frustration about their mental health needs not being addressed. Despite repeated requests from the resident for a psychological evaluation and clear indications of ongoing emotional distress, there was no evidence that the facility made or completed the necessary referral for behavioral health services. Staff interviews confirmed that there was no documentation of a referral being made, and the Director of Nursing acknowledged that the order for a psychological evaluation was still pending without explanation. This lack of action resulted in the resident not receiving the behavioral health services required to address their mental health needs.