Failure to Implement Psychiatric Evaluation Orders for Depressed Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for psychiatric evaluation and treatment and to incorporate these services into the care plans for two residents with diagnosed depression. Facility policy on Behavioral Assessment, Intervention and Monitoring requires nursing staff to identify and report changes in mental status and for the IDT to evaluate behavioral symptoms and underlying causes. Despite this, Resident 1, admitted with major depressive disorder, cognitive communication deficit, and a history of alcohol abuse, had a hospital discharge order for Paroxetine that was not continued in the facility, and no other antidepressant was prescribed from admission through several months. Resident 1’s MDS identified depression and documented symptoms such as feeling tired, poor appetite, feeling life was a failure, and little interest or pleasure in activities, yet the psychiatric evaluation and treatment orders dated shortly after admission were not carried out. For Resident 1, multiple clinical notes documented ongoing depressive indicators and functional decline without corresponding psychiatric intervention or care plan updates. The NP ordered a psychiatric referral to assess for depression, and therapy notes showed repeated refusals of PT and OT, low motivation, and refusal to get out of bed. A care plan was initiated for feelings of loneliness and later for refusing showers, and social services documented that the resident “shut down” and became nonverbal after being informed of a pending divorce. CNA interview confirmed the resident was upset about the divorce and minimally participated in personal hygiene. The SSD acknowledged that no counseling or psychological evaluation was provided and that no new care plan or change-in-condition assessment was initiated after the emotional event. The DON confirmed that the psychiatric referral “got away from them” and that the resident received no psychiatric services while in the facility, and the NP acknowledged being unaware that the psychiatric evaluation had not occurred. Resident 2 was admitted with major depressive disorder, cognitive decline, and cancer, and the MDS documented mild cognitive impairment and depression, including feeling bad about self, being down and depressed, having little pleasure in activities, and difficulty staying asleep. Physician orders included psychiatric referral, evaluation, and treatment on two separate dates, but no psychiatric evaluations were found in the medical record. NP progress notes documented monitoring for signs and symptoms of depression, including episodes of crying and poor oral intake, yet there was no evidence that the psychiatric referrals were implemented. RN B confirmed the absence of psychiatric evaluation or treatment documentation and stated that the nurse receiving the psychiatric referral order is responsible for entering it into the EHR and coordinating care. Additional interviews with activities and social services staff described the resident as emotional, crying, and upset about dying, further indicating ongoing depressive symptoms without documented follow-through on ordered psychiatric services. This failure resulted in both residents not receiving mental health evaluation and had the potential for them not to reach their highest practicable level of mental and psychosocial well-being.
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