Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with Alzheimer's disease, depression, and a history of expressing sadness and making negative statements did not receive a psychiatry consult as previously recommended by a psychiatric provider. The facility's policy required behavioral health services to be provided as needed, but there was no evidence that a psychiatry consult was ordered or completed for the resident, despite documented recommendations and family requests. The resident's care plan included interventions such as psychiatry/psychology consults and monitoring for mood changes, but these interventions were not fully implemented. Multiple staff interviews and record reviews revealed that the facility experienced a lapse in psychiatric provider coverage due to the previous provider discontinuing services and delays in securing a replacement. During this period, the resident's family expressed concerns about negative and potentially suicidal statements, requesting a psychiatric evaluation. Nursing staff implemented increased monitoring and communicated with the nurse practitioner, who evaluated the resident and recommended a psychiatry consult. However, no order for a psychiatry consult was placed, and the recommendation was not followed through. Further interviews indicated breakdowns in communication and follow-up among nursing, social work, and administrative staff. The social work department was unaware of the resident's negative statements and did not complete an assessment or facilitate a psychiatric referral. The nurse practitioner did not place an order for a psychiatry consult, citing the absence of an in-house provider at the time. The administrator and director of nursing acknowledged gaps in the process, including lack of documentation, missed follow-up, and unclear protocols for handling provider recommendations and psychiatric referrals.