Failure to Timely Initiate Psychiatric Services for Resident on Antipsychotic Therapy
Penalty
Summary
The facility failed to provide necessary behavioral health care and services by not timely initiating psychiatric services for a resident admitted with significant behavioral and cognitive issues. The resident was admitted with Alzheimer's disease, restlessness, and agitation, and had a Brief Interview for Mental Status score of 0/15, indicating severely impaired cognition. The resident required staff assistance with bed mobility and transfers. Physician orders at admission included scheduled Olanzapine 5 mg orally every 12 hours as an antipsychotic and a psychiatric consult related to aggression toward staff, including throwing water at staff and refusing care, with consult start dates documented as 9/9/2024 and 10/13/2024. Despite these orders and the resident’s behavioral concerns, the medical record showed that consent to receive psychiatric services was not obtained until 12/12/2024, approximately three months after admission. No psychiatric visit notes were available in the record and were not provided to surveyors upon request. Social work staff interviewed during the survey stated that the usual process is to obtain consent for psychiatric services upon admission for residents on regular antipsychotic medications and to send a referral to the psychiatric provider, but they were unable to explain why this did not occur for this resident. The facility’s Behavioral Health and Management policy states that it is the policy of the facility to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents in accordance with their plan of care, which was not followed in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.