Failure to Complete Ordered Psychological Consultation for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with diagnosed mental health conditions received a psychologist consultation as ordered by the physician. The resident was admitted with diagnoses of depression, anxiety disorder, and insomnia. An MDS assessment dated 12/30/2025 documented moderately impaired cognition and a need for setup assistance with eating and partial assistance with other ADLs such as bathing, dressing, and toileting. Physician orders dated 12/24/2025 and 12/26/2025 directed that the resident receive a psychological evaluation, follow-up treatment as indicated, and a psych consultation for depression and anxiety. Record review and staff interviews confirmed that the ordered psychological services were not completed. During an interview and concurrent record review, an RN acknowledged that a psych consultation had been ordered for the resident but was not carried out, and stated that the order should have been completed as written. The DON similarly stated that a psych consult should be completed if ordered by the physician. The facility’s Behavioral Assessment, Intervention, and Monitoring policy, revised 3/2019, indicated that the facility will provide behavioral health services as needed for residents to attain or maintain their highest practicable mental, physical, and psychosocial well-being, but this was not followed for this resident.
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