Failure to Provide Required Mental Health Services to a Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary mental health services to a resident with multiple serious mental health diagnoses. The resident, who had bipolar disorder, conversion disorder, anxiety disorder, PTSD, panic disorder, delusional disorder, and dementia, was admitted after an extended inpatient psychiatric hospital stay. Initial physician orders dated 9/5/25 authorized psychiatric services, counseling, and medication management, and consent for behavioral health services was obtained from the resident’s next of kin. A care plan initiated on 9/8/25 identified anxiety with an intervention of psychiatric services per order. However, a physician’s order allowing evaluation and treatment for psychology and psychiatry services was discontinued on 10/12/25, and a level of care document dated 11/17/25 showed zero days of psychological therapy. A PASSAR dated 11/19/25 required the facility to provide mental health services such as individual therapy. The clinical record contained no documentation of mental health services from 9/5/25 to 1/11/26. On 1/12/26, a psychiatric telehealth visit determined the resident was eligible for behavioral health integration and psychiatric collaborative care management, and the resident consented to enroll. Care plans dated 2/6/26 documented PTSD, use of antipsychotic medications, and a history of severe, persistent mental illness, with interventions to refer the resident to psychiatric services, appropriate individual counseling or other mental health programs, and to involve the resident in supportive group or one-on-one counseling. A psychotropic drug evaluation dated 3/5/26 indicated the resident was receiving psychiatric services, yet the clinical record again lacked documentation of mental health services from 1/13/26 to 3/26/26. A quarterly social service interview on 3/10/26 recorded moderate depression symptoms with a PHQ-9 score of 13. During observations and interviews, the resident reported not receiving mental health services, stated she would like to attend therapy, and said staff had not asked if she wanted therapy. Staff interviews confirmed the resident was not currently being seen by a psychiatric provider or receiving mental health services, and the DON stated the facility did not have a policy regarding mental health services.
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