Failure to Provide Behavioral Health Services Following Resident Request
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary behavioral health care and services to a resident who requested mental health counseling. The resident, admitted with a history of alcohol abuse (in remission), exhibited consistent emotional behaviors and expressed concerns about her care and treatment by staff from the time of admission. She reported feeling mistreated, submitted a grievance regarding staff interactions, and specifically requested a different provider after expressing dissatisfaction with her assigned provider. Despite these documented concerns and requests, the resident did not receive access to mental health counseling or services during her stay. Interviews with facility staff revealed that the resident's emotional and behavioral issues were recognized by staff, including daily fluctuations in mood and difficulty settling into the facility. Staff acknowledged the resident's request for mental health services and noted her history of mental health concerns. However, there was no documentation of any referrals made for counseling, therapy, or mental health services, even though the facility's policy required monitoring, documentation, and appropriate follow-up for behavioral health needs. The social services staff member responsible for coordinating such services confirmed that no referrals were made, and the facility was unable to provide documentation of any behavioral health service referrals for the resident. The resident's medical record and care assessments consistently documented her emotional distress, paranoia about medications, and ongoing conflicts with staff. Multiple progress notes described her as excitable, emotional, and having difficulty regulating her emotions. The facility's own behavioral health policy outlined the need for timely assessment and referral for behavioral health services, but these steps were not completed for the resident, despite clear indications and requests for such support.