F0740

D

Failure to Provide Mental Health Services for Resident With Schizophrenia and Depression

Pullman, Washington Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident with known schizophrenia and moderate depression received necessary mental health services during their stay. The resident was admitted with diagnoses including a fractured right hip and schizophrenia, and their admission MDS documented a depression screening with a score indicating moderate depression. The resident’s care plan identified a focus on paranoid schizophrenia with delusions, hallucinations, and paranoia, and included an intervention for a psychiatric consult as needed. Progress notes documented that the resident had a history of three prior suicide attempts, the most recent in 2019 following the unexpected death of their mother, and that they had scored moderately depressed on a PHQ-9 assessment.

Nursing progress notes repeatedly described the resident as anxious and/or restless on multiple occasions and at various times, yet the electronic medical record showed no evidence that the resident had been seen by any mental health provider during their stay. In an interview, the resident reported a long history of schizophrenia since their teen years, frequent hospital and facility admissions, traumatic life experiences, and concern about their future after discharge. The resident stated they believed they would benefit from mental health services and that such services had always been offered and utilized in other medical settings, but none had been offered at this facility. In a separate interview, the Social Services Director confirmed that the resident had expressed interest in mental health services and was thought to benefit from them, but stated the facility was not contracted with any mental health provider and that no mental health services were available.