Failure to Provide Behavioral Health Care and Services for Residents with SUD and Suicidal History
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to ensure residents received the highest practicable mental and psychosocial well-being. Specifically, the facility did not create comprehensive assessments or care plans to address a substance use disorder (SUD) for one resident and failed to address a history of suicidal ideations and attempts for another resident. The surveyor found that the facility did not have a substance abuse policy, and the care plans for both residents lacked goals, interventions, and monitoring related to their behavioral health needs. One resident with a documented SUD, including alcohol and cocaine abuse, was admitted with multiple related diagnoses such as alcohol-induced chronic pancreatitis and end-stage renal disease. Despite evidence of ongoing alcohol consumption, including the discovery of empty vodka bottles in the resident's room and a missed dialysis session, the facility did not develop or implement a care plan addressing the resident's substance use, triggers, or associated behaviors. The social worker was unaware of the resident's SUD and no referral to the facility's substance use program was made, as referrals were only initiated with a physician or NP order, not based on active diagnoses. Another resident with a history of conversion disorder, PTSD, personality disorder, and multiple suicide attempts was not provided with a care plan addressing suicidal ideations or attempts. The care plan did not include any goals, interventions, or monitoring for suicide risk, despite the resident's extensive history of attempts, including recent overdoses and self-harm. Staff interviews confirmed that such histories should be care planned to inform monitoring and interventions, but this was not done, and no precautions or monitoring were in place for the resident's behavioral health needs.