Failure to Complete and Document Psychiatric Evaluation After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received necessary behavioral health services following an altercation. The resident was admitted with diagnoses including muscle weakness and difficulty walking. After a verbal altercation with another resident in which the resident attempted to hit the other party, an IDT care conference was held and documented on 10/27/25. The IDT recommended a psychiatric evaluation and treatment for episodes of agitation. The physician subsequently entered an order on 10/29/25 for a psychiatric evaluation and treatment related to agitation. Despite this, there was no documentation in the resident’s medical record that a psychiatric evaluation occurred or that psychiatric treatment was provided. During interviews and concurrent record reviews, the ADON, SSA, and DON each confirmed key gaps in the referral and documentation process. The ADON acknowledged the IDT recommendation for a psychiatric evaluation and stated she was not sure if the referral had been completed, noting that social services needed to be informed when such referrals were required. The SSA confirmed that social services were responsible for sending psychiatric referrals and that a psychiatrist contracted with the facility typically visited and documented in an external portal, but she did not have access to that portal and was unsure if the resident had been seen; she also confirmed there were no psychiatric notes in the EHR. The DON confirmed the resident’s history of agitation, the altercation details, and the existence of the physician’s psychiatric evaluation order, but stated she did not know if the resident had been seen and also lacked access to the psychiatrist’s portal. The DON verified that no psychiatric notes were present in the resident’s chart and stated it was important for the facility to know the psychiatrist’s recommendations and that without this information the facility would not be compliant with psychiatric services, affecting the resident’s psychosocial health.
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