Sunny Village Care Center staff failed to follow their own protocol for psychiatric consultations ordered for Resident 1, according to a December 23 federal inspection. The consultation was ordered on November 25, but nursing staff never followed through to ensure the psychiatrist received the referral or completed the evaluation.
RN 2 told inspectors the facility's protocol requires nursing staff to inform Psychiatrist 1 of any consultation order the same day it's written. The psychiatrist or physician assistant should then visit the facility the next day to conduct the evaluation.
"Resident 1 should have had a psych consult before December 21, unless he refused," RN 2 said during the inspection interview.
But no such evaluation occurred.
Licensed Vocational Nurse 1 acknowledged the consultation had been ordered "two to three weeks ago" and admitted she didn't think the resident had been seen yet. When asked why not, she said she was busy and didn't follow up to see if the consultation was endorsed or completed.
The failure to provide psychiatric care carries serious consequences for residents with behavioral health needs. According to facility policy, acute behavioral episodes can include aggressive behaviors, violent behaviors, or potential danger to self or others including staff. Without proper psychiatric evaluation and treatment, these episodes can escalate to the point where "Resident 1 not being able to be cared for in the facility."
RN 2 emphasized the importance of the psychiatric consultation during her interview with inspectors. She explained that only Psychiatrist 1 has the expertise to evaluate whether there are new problems affecting the resident's mental health.
"If the evaluation is not done, appropriate modifications and or treatments cannot be provided to the resident," she said.
The nursing staff's failure violated multiple layers of the facility's own procedures. LVN 2 explained that nursing staff should have endorsed the ordered consultation each shift to ensure follow-up and completion. If the resident had refused the evaluation, staff were required to document the refusal and notify the doctor.
None of that happened.
When RN 1 reviewed Resident 1's electronic and physical medical charts with inspectors on December 23, the records showed a complete absence of documentation. From November 25 through December 18, there was no indication of any offered or completed psychiatric consultations, no doctor notifications, no follow-up attempts, and no documentation of refusals.
RN 1 confirmed that the medical chart should have contained documentation of any refusals, physician notifications, care plan modifications related to refusals, or completed evaluations.
The facility's own policy, titled "Behavioral Assessment, Intervention and Monitoring," requires staff to provide residents with behavioral health services "as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being." The policy specifically mandates that the interdisciplinary team thoroughly evaluate new or changing behavioral symptoms to identify underlying causes, including "emotional, psychiatric and/or psychological stressors" that may have contributed to changes in the resident's condition.
For nearly a month, Resident 1 remained without the psychiatric evaluation that could have identified treatment modifications or interventions to address behavioral symptoms. The gap in care left the resident at risk for escalating behavioral episodes that nursing staff acknowledged could threaten the resident's ability to remain at the facility.
The inspection found that nursing staff understood the protocol but simply failed to execute it. Multiple nurses confirmed they knew the psychiatrist should have been contacted immediately and should have evaluated the resident within a day of the consultation order.
Instead, the resident went without psychiatric care while staff members remained too busy to follow up on critical mental health services. The failure represents a breakdown in the facility's interdisciplinary approach to resident care, where coordination between nursing staff and psychiatric providers is essential for maintaining residents' mental health stability.
Federal regulations require nursing homes to provide necessary services to help residents achieve their highest level of physical, mental and psychosocial well-being. The three-week delay in psychiatric consultation at Sunny Village Care Center left one resident without the specialized mental health evaluation that facility staff acknowledged was crucial for preventing behavioral crises that could jeopardize the resident's placement.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunny Village Care Center from 2025-12-23 including all violations, facility responses, and corrective action plans.