Failure to Provide Timely Behavioral Health Services
Penalty
Summary
A deficiency occurred when a resident with dementia, identified as being at risk for verbal aggression, did not receive timely behavioral health care as required. The resident's care plan included interventions such as a psychiatric or psychogeriatric consult as indicated. Over a period of time, the resident exhibited multiple episodes of agitation, verbal aggression, wandering, and combative behavior, including incidents where the resident was uncooperative with therapy, called 911 while confused, and was verbally aggressive toward staff and family. Despite these ongoing behavioral health concerns, documentation showed that a referral for a psychiatric consult was sent, but there was no evidence that the resident was seen by psychiatric services. Further review of facility records revealed that the resident was not listed to be seen by the psychiatric provider, and electronic communication logs indicated that requests for consultation went unanswered for 30 days, with a follow-up message sent 12 days prior to the survey. Staff interviews confirmed that the resident had not been seen by psychiatric services, despite the ongoing behavioral health issues and the care plan's directive for such intervention. This failure to provide necessary behavioral health care and services in a timely manner resulted in the deficiency.