Failure to Provide Scheduled Psychotherapy and Timely Follow-Up
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with adjustment disorder with depressed mood and anxiety disorder. The resident had a physician's order for psychotherapy sessions twice a week, as documented in the psychologist's progress notes and the doctor's order summary. However, both scheduled psychotherapy sessions during a specific week were missed, with no documentation indicating that services were provided or that alternative interventions were implemented. Licensed nursing staff confirmed the missed visits and acknowledged the absence of follow-up or backup plans. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed that the process for handling missed psychotherapy appointments required communication and timely follow-up, which did not occur in this instance. The Social Services Department was responsible for managing psychology referrals and appointments, and staff were expected to notify appropriate personnel if a visit was missed. Despite these expectations, there was no evidence that the missed psychotherapy sessions were addressed, placing the resident at risk for negative psychosocial outcomes.