F0745

D

Failure to Arrange Psychology Consult After Onset of Aggressive Behaviors

Compton, California Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to arrange a psychology consult for a resident after the onset of aggressive behavioral symptoms, despite multiple assessments and care plans indicating the need for such an evaluation. The resident had diagnoses including peripheral vascular disease, PTSD, and major depressive disorder, and was documented as having the capacity to understand and make decisions. An MDS assessment showed modified independence in cognitive skills for daily decision-making and a need for moderate assistance with toileting, dressing, and personal hygiene.

On 11/27/2025, an SBAR documented that the resident exhibited behavioral symptoms, including agitation when frustrated and a belief that he was being targeted by staff. Following this change in condition, the resident’s care plans titled “Aggressive Outbursts” and “Behavioral Symptoms,” dated 11/27/2025 and 11/28/2025 respectively, identified aggressive behavior, verbal abuse, and sudden angry outbursts, and specifically included interventions for a psychological evaluation. An IDT conference record dated 11/28/2025 showed that the team met with the resident to discuss verbal aggression toward staff and recommended a referral to psychology for a consultation.

Despite these documented recommendations and care plan interventions, interviews and record review revealed that no psychology evaluation was completed and no psychology note was found in the resident’s medical record after the behavioral change on 11/27/2025. The SSD stated that when the IDT recommended a psychology referral, the referral should be made so the psychologist could evaluate the resident as soon as possible after behavioral symptoms. The psychologist reported he did not recall being informed of the resident’s behavioral change and stated he had not been made aware of the need for an evaluation. Facility staff, including the SSD and RN 1, stated that psychological evaluations were important for residents to express feelings, identify root causes of behavior, and develop coping skills, and that without the recommended evaluation the resident was at risk for psychological distress, poor coping skills, and continuation of aggressive behavior. The facility’s behavioral health policy and the Social Services Designee job description indicated that the facility was responsible for providing behavioral health services as needed and coordinating with outside psychology professionals, which did not occur in this case.