Failure to Provide Behavioral Health Services for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to provide behavioral health care services to a resident with diagnosed serious mental illness and ongoing behavioral symptoms. The resident was discharged from the hospital with diagnoses including bipolar I disorder, current manic with psychotic features, and schizophrenia, and the hospital discharge summary documented a need for follow-up psychiatric appointments and medication management. On admission, the resident’s care plan dated 01/23/26 did not include a focus area for behaviors despite these diagnoses and the presence of multiple psychotropic medications, including olanzapine, lamotrigine, and fluphenazine decanoate. The admission MDS indicated intact cognition, no behaviors coded during the lookback period, and a Level II PASRR, and the resident was coded as receiving antipsychotic medications. Behavioral documentation on the MAR from 01/23/26 through 02/13/26 showed repeated episodes of calling out and screaming/calling out on multiple days, yet the medical record from 01/23/26 through 02/16/26 contained no evidence that psychiatric or other behavioral health services were provided. During observation on 02/16/26, the resident’s call light remained on while he yelled for assistance for over 20 minutes, and a med aide acknowledged that he frequently yelled out but did not know how long he had been yelling on that occasion. The admitting nurse stated she did not recall seeing a psychiatry referral, explained that her process was to place such referrals in the social worker’s box, and did not know why the resident had not been seen by psychiatry despite his behaviors. The Social Services Director confirmed she had not received a referral or completed a psych consent for this resident and that the resident was not on the psychiatric provider’s active list. The Medical Director and DON both stated they expected residents to receive necessary behavioral health care services and were unaware that this resident had not been referred to or seen by psychiatric providers.
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