Failure to Provide Behavioral Health Services for Resident with Depression and Substance Dependence
Penalty
Summary
A deficiency was identified when the facility failed to provide appropriate behavioral health services to a resident with a history of opioid dependence, depression, and homelessness. The resident was admitted for long-term care due to the need for 24-hour assistance with activities of daily living, skilled nursing care, and medication management. Upon admission and during subsequent evaluations, the resident reported ongoing moderate depression, anxiety, and insomnia, which were attributed to his life circumstances, including homelessness and health issues. Psychiatric evaluations recommended increasing antidepressant medication and specifically advised psychotherapy for ongoing depression, with the resident agreeing to the plan of care. Despite these recommendations, the facility did not arrange for the resident to receive psychotherapy or ensure follow-up with an addiction specialist as documented in the medical record. Interviews with the Social Work Assistant revealed that they were unaware of the recommendation for psychotherapy and had no documentation that such services were provided. Additionally, there was no evidence that the resident was seen by an addiction specialist, despite multiple notes indicating referrals were needed for addiction medicine and withdrawal management. Facility policy required that residents exhibiting behavioral health needs be reviewed by a Behavior Management team and that individualized plans of care, including non-pharmacological interventions, be implemented. However, the resident was only seen by behavioral health providers on two occasions, and no ongoing psychotherapy or addiction specialist services were documented. This lack of follow-through on recommended behavioral health interventions constituted the deficiency.