Failure to Process Psychiatric Referral for Resident with Depression
Penalty
Summary
A deficiency occurred when the facility failed to ensure the psychosocial well-being of a resident by not processing a psychiatric referral in a timely manner. The resident, who had a history of hemiplegia, hemiparesis following a stroke, malignant neoplasm of the colon, and recent colon surgery, was admitted with significant medical and emotional needs. An order for a psychiatric referral was entered by a Nurse Practitioner after the resident was observed with tears in her eyes and refusing therapy. However, the Social Services Department did not process this referral as required, and the resident did not receive the intended psychiatric evaluation. During interviews, the resident expressed feelings of sadness, loneliness, and depression related to her medical condition and stay at the facility, stating she had not been offered counseling or therapy. The Social Services Director confirmed that the referral process was not completed, and the DON acknowledged the importance of timely referrals for residents' mental health. The Nurse Practitioner who ordered the referral was unaware it had not been completed, and facility policy required social services to coordinate and document such referrals in collaboration with nursing staff.