Failure to Provide Ongoing Behavioral Health Services and Implement Psychosocial Care Plan
Penalty
Summary
The facility failed to implement a care plan for psychosocial and mental well-being and to provide necessary behavioral health services for a resident with multiple mental health diagnoses, including bipolar disorder (current episode depressed), major depressive disorder, restlessness and agitation, and a history of seizures and chronic pain. The resident’s MDS showed intact cognition, and the care plan identified a need for specialized rehabilitation, support, counseling, and/or psychotherapeutic services, including mental health services such as psychotherapy, life skills training, and substance abuse services. Interventions in the care plan included obtaining consent, assisting the resident in locating an appropriate treatment provider, making initial appointments, and arranging transportation as necessary. The record showed that client-centered therapy sessions occurred on several documented dates, with the last session indicating the therapist would continue individualized biweekly therapy for six months, but no further therapy sessions were documented after that date. The Social Service Director reported that the facility had outside providers who came twice weekly for support groups and 1:1 sessions, and another provider offering intensive outpatient group therapy off-site, but she was not aware that the resident participated in any of these services and could not provide documentation of the resident’s participation in structured group or individualized mental health sessions. She also stated that the facility’s Social Services Department did not conduct any therapy groups or individualized sessions to address residents’ mental health needs. Progress notes later documented that the resident stated being depressed due to a sister’s death, expressed a desire to go to the hospital, and reported self-harm by cutting the right wrist with scissors, with bleeding observed. The resident was sent to the hospital via 911, returned the same day with stitches and was placed on 1:1, then was petitioned for involuntary discharge for psychiatric evaluation and was issued an involuntary discharge, not being allowed to return. A suicide/self-harm screening documented the resident as presenting a low to moderate risk for self-harmful behavior and recommended integration with structure, direction, and supportive counseling. The facility’s Social Services policy stated that it is the policy to provide a competent variety of psychological programming and therapeutic recreation opportunities to meet each resident’s mental and psychosocial well-being needs.
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