Failure to Obtain Psychiatric Evaluation After Abuse Allegation and Positive Trauma Screen
Penalty
Summary
Facility staff failed to obtain a psychiatric consultation for Resident #3 despite multiple indicators and orders requiring such services. The resident had diagnoses including muscle atrophy, lack of coordination, difficulty walking, depression, gout, and osteomyelitis, and had been deemed capable of making medical decisions by the physician. On 12/06/24, the resident screened positive for a history of trauma and past PTSD, and a depression care plan was initiated the same day, identifying the resident as at risk for depression with a positive trauma screen. Interventions in the care plan directed staff to notify the provider for any risk of harm to self or others and to observe for signs of depression such as hopelessness, anxiety, sadness, tearfulness, and repetitive anxious or health-related complaints. On 03/26/25, a physician’s order instructed nursing staff to obtain a psychological/psychiatric evaluation upon admission and as needed due to the positive trauma screen. On 08/31/25, an incident occurred in which an LPN allegedly told other nursing staff not to provide care to Resident #3 and stated that pain medication would not be administered. Following this, the facility conducted an abuse investigation related to these allegations. The resident also had a behavior care plan initiated on 09/02/25 for yelling out for assistance instead of using the call bell, with interventions including discussing the behavior with the resident when reasonable, explaining why the behavior was inappropriate, anticipating and meeting needs, monitoring episodes of behavior, and documenting behaviors and potential causes. Despite the physician’s order for psychological/psychiatric evaluation and the facility’s determination during its follow-up investigation that the resident should be referred to the facility Geri-Psych service provider, the DON confirmed that the resident was never assessed by the Geri-Psych consultant after the abuse allegation was brought to the facility’s attention.
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