Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with a history of alcohol abuse, extreme trauma, and mental health disorders. The resident was assessed as cognitively intact with minimal depression and had a goal to return home. Although the resident declined in-house psychiatry services, the care plan did not address opportunities for autonomy, community connections, or support for cultural and religious practices. The care plan also lacked a thorough, person-centered description of the resident's distress and did not include measurable interventions or programs to assist the resident in achieving optimal mental and psychosocial functioning. The resident experienced a decline in mental health, which manifested in aggressive and abusive behaviors toward staff and another resident, as well as multiple incidents involving law enforcement and hospitalizations. Documentation showed that the resident was prescribed medications for mood and sleep, but non-pharmacological interventions such as redirection and one-to-one visits were not clearly defined in purpose or intent. The care plan did not specify the rationale for these interventions, and there was no evidence of reassessment or updates to the care plan following significant behavioral incidents, substance use, or psychiatric hospitalizations. Interviews with facility staff revealed a lack of awareness and action regarding the provision of chemical dependency treatment, trauma-informed care, or psychosocial therapies tailored to the resident's needs, especially considering language barriers and the resident's history of trauma and substance abuse. The social services director confirmed that no chemical dependency or therapeutic interventions were offered, and the director of nursing was unaware of any such services being provided. The facility was unable to provide a policy for treatment and/or services for mental and psychosocial concerns, and the medical record did not reflect that appropriate support, treatment, or services were provided to help the resident attain the highest practicable mental and psychosocial well-being.