Failure to Provide Appropriate Psychiatric Services for Residents with Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that residents diagnosed with mental illness, psychosocial adjustment difficulties, or a history of trauma and/or post-traumatic stress disorder received appropriate treatment and services to address their assessed problems and attain the highest practicable mental and psychosocial well-being. Specifically, three residents with significant behavioral health needs did not receive adequate psychiatric services. The deficiency was identified through interviews and record reviews, which revealed gaps in the provision of individualized psychiatric care and counseling. One resident with severe dementia, anxiety disorder, alcohol-induced persisting dementia, and a history of trauma exhibited multiple behavioral issues, including wandering, aggression, inappropriate exposure, and self-injurious behaviors. Although the care plan included interventions such as arranging for a licensed mental health provider and monitoring for escalating symptoms, documentation showed ongoing behavioral challenges and repeated psychiatric notes that primarily focused on medication management. The psychiatric provider's notes often indicated that non-pharmacologic interventions had been ineffective, but there was little evidence of ongoing, individualized psychiatric counseling or assessment of the resident's emotional state in relation to recent incidents. Another resident with major depressive disorder and chronic diarrhea reported feeling that psychiatric visits were superficial and did not address his emotional needs or recent conflicts with a roommate. He stated that the psychiatrist did not inquire about his feelings or the impact of recent altercations, and that visits were conducted in the presence of his roommate, making him uncomfortable to share openly. A third resident with mild intellectual disabilities, major depressive disorder, and generalized anxiety disorder also reported that psychiatric visits did not address his behavioral outbursts or emotional well-being, with interactions focusing on casual topics rather than his mental health needs. These findings demonstrate a lack of comprehensive psychiatric assessment and individualized counseling for residents with behavioral health needs.