Failure to Ensure Ongoing Psychiatric Services for Resident with Mental Health Diagnoses
Penalty
Summary
A resident with a history of multiple psychiatric diagnoses, including anxiety, depression, schizoaffective disorder, and post-traumatic stress disorder, did not receive ongoing psychiatric services as required. The resident had previously attended psychiatric appointments outside the facility, with the last documented visit occurring several months prior to the survey. Despite being scheduled for regular follow-up every two months, there was no documentation or explanation for the missed appointments, and the resident confirmed he had not attended psychiatric services for an extended period and was unsure of the reason. Medical records indicated the resident was prescribed several psychotropic medications, including Latuda, Trazadone, Prozac, and buspirone, and his care plan identified him as being at risk for behavioral symptoms related to past trauma. The care plan included interventions such as allowing the resident to discuss emotions in a safe environment and consulting mental health services as needed. However, there was no evidence that the facility ensured the resident continued to receive psychiatric evaluations or medication management as outlined in his care plan and physician's notes. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's missed psychiatric appointments. The DON was unaware that the resident had not been seen by psychiatric services, and the social worker was unfamiliar with the resident's outside psychiatric care. The process for tracking and scheduling follow-up appointments was unclear, and responsibility for ensuring ongoing psychiatric care was not consistently assigned or monitored, resulting in the resident not receiving necessary behavioral health services.