Failure to Provide Timely Psychosocial Assessment and Services After Significant Emotional Change
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, mental illness, and homelessness, who was assessed as having wandering and exit-seeking behaviors, did not receive appropriate treatment and services following a significant emotional event. After the discharge of a close companion from the facility, the resident exhibited increased wandering, emotional distress, and refusal of medications. Despite these changes, there was no documented evidence that a psychosocial assessment was completed to address the resident's altered mental and psychosocial state. The resident's care plan identified risks related to cognitive impairment and adjustment issues, and interventions included monitoring medication effectiveness and providing support for psychosocial wellbeing. However, the resident frequently refused prescribed antipsychotic medication, and the high rate of missed doses was not communicated to medical practitioners. Additionally, after the resident returned from an unauthorized absence and following the discharge of their companion, staff did not assess the resident's mood or risk for depression or suicide, despite facility policies requiring such assessments after significant emotional changes. The situation escalated when the resident was found on the ground outside the facility after removing an air conditioner from a window, resulting in multiple fractures and hospitalization. Upon readmission with a new diagnosis of suicide attempt, there was still no documented assessment for depression or suicide risk until several days later. Interviews with staff and medical personnel confirmed that the resident's emotional state should have been assessed after both the companion's discharge and the resident's readmission, but these assessments were not completed in a timely manner.