Failure to Provide Timely Behavioral Health Services and Referrals
Penalty
Summary
The facility failed to ensure that a resident with multiple behavioral health diagnoses received necessary behavioral health care and services. The resident, who had Parkinson's Disease, dementia without behavioral disturbance, insomnia, and major depressive disorder, exhibited ongoing sexually inappropriate and compulsive behaviors, as well as an episode of self-harm. Despite physician orders for psychiatric referrals and behavior monitoring, there were significant delays in the resident being seen by psychiatric providers after referrals were made, and recommended therapy services were not initiated. Documentation showed that staff made psychiatric referrals on two occasions, but the resident was not seen by the psychiatric provider until several months later. Additionally, after a psychiatric evaluation recommended therapy services, there was no evidence that the resident was ever referred for or received therapy. Staff interviews revealed a lack of clarity and an ineffective process for tracking and ensuring that referrals were communicated and acted upon. The Social Services Director (SSD) and Director of Nursing (DON) both confirmed there was no tracking method to ensure referrals were sent and followed up, and the psychiatric provider was not always notified of new or urgent behavioral concerns. The resident's medical record and staff interviews further confirmed that non-pharmacological interventions for depression were not in place, and the resident was not receiving counseling or therapy services as recommended. The psychiatric nurse practitioner also confirmed gaps in communication regarding referrals and behavioral incidents, resulting in missed opportunities for timely psychiatric follow-up and intervention.