Delay in Providing Requested Behavioral Health Services
Penalty
Summary
The facility failed to provide timely behavioral health services to a resident who requested psychological therapy. The resident, admitted with muscular dystrophy and cognitively intact with a BIMS score of 15, had a PHQ-9 score of 17 indicating moderately severe depression. In mid-January 2026, the resident told the Ombudsman that he wanted talk therapy. The Ombudsman relayed this request to the Social Services Director (SSD), who stated she verbally informed the Director of Nursing (DON) the same day that the resident was asking for psychological therapy. Despite this, no referral for mental health services was initiated at that time. The DON later stated she was not aware of the resident’s request on 1/14/26 and only became aware of it on 2/19/26 after receiving an email from the Ombudsman to the SSD stating that the resident wanted psychological treatment. The referral for treatment was not started until 2/25/26, and the resident was not seen by a psychiatrist or psychologist until 3/2/26, resulting in a 45-day wait from the initial request. During this period, the resident reported feeling like he was going crazy, hearing things loudly, being unsure if the voices were real, being unable to sleep at night, and having no energy during the day. Observation showed the resident sitting quietly in activities and not interacting with others. The DON acknowledged that without timely intervention, the resident could escalate to severe depression with associated decline in ADL function. The facility’s Behavioral Health Services policy stated that residents will receive behavioral health services as needed to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
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