Failure to Provide Timely Psychiatric Consult Following Acute Behavioral Change
Penalty
Summary
The facility failed to provide a timely psychiatrist or psychologist consult for a resident who experienced an acute behavioral change, as ordered by the physician and outlined in the care plan and facility policy. The resident, who had diagnoses including diabetes mellitus, hypertensive heart disease with heart failure, and difficulty walking, was admitted with intact cognitive skills and independence in daily activities. On the date of the behavioral change, the resident exhibited verbal aggression and refused a blood glucose fingerstick, prompting a physician's order for a psychiatric consult and an update to the care plan to include this intervention. Despite the order and care plan intervention, the psychiatric consult was not provided for 25 days. Interviews with nursing staff revealed that the facility's protocol required nursing to notify the psychiatrist of such consults the same day, with the expectation that the psychiatrist or physician assistant would evaluate the resident the following day. However, the psychiatrist was not informed of the consult order until he was at the facility for routine rounds nearly a month later. Nursing staff acknowledged that they did not follow up or endorse the consult order on subsequent shifts, and there was no documentation of the consult being offered, completed, refused, or of any physician notification during this period. A review of the resident's medical chart confirmed the absence of documentation regarding the psychiatric consult, refusals, or follow-up actions. Facility policy required thorough evaluation of new or changing behavioral symptoms by the interdisciplinary team to identify underlying causes, including psychiatric or psychological stressors. The lack of timely notification and follow-up by nursing staff resulted in the resident not receiving the ordered psychiatric evaluation as required by the physician's order, care plan, and facility policy.