Failure to Implement Behavioral Health Interventions for Aggressive Resident
Summary
The facility failed to ensure necessary behavioral health care and services were provided to a resident, identified as RI #335, who exhibited physically and verbally aggressive behaviors, as well as homicidal and suicidal ideations. On one occasion, RI #335 was sent to the hospital emergency room after being physically and verbally abusive to staff and expressing homicidal and suicidal ideations. Upon returning from the hospital, the facility did not develop a plan to ensure the safety of other residents, nor were any new orders or interventions implemented. The deficiency was highlighted when a Certified Nursing Assistant (CNA) witnessed RI #335 in another resident's room, attempting to smother the resident with a pillow. This incident occurred shortly after RI #335's return from the hospital, during which time no nursing assessment was conducted, and no interventions were put in place to address the resident's aggressive behaviors. Interviews with facility staff revealed that there was an expectation that the hospital would have kept RI #335, and as a result, no immediate interventions were planned upon the resident's return. The facility's policy on Behavioral Health Services was not adhered to, as it mandates that necessary behavioral health care services be person-centered and reflect the resident's goals for care while ensuring safety. Despite RI #335's history of aggressive behavior and cognitive impairment, the facility did not implement appropriate interventions or conduct a comprehensive assessment upon the resident's return from the hospital, leading to a situation that posed a risk of serious harm to other residents.
Removal Plan
- Resident #335 was redirected from the Dining room by the Administrator after yelling, throwing things and grabbing at staff.
- Social services made referrals for Psych services related to physical and verbally abusive behaviors and suicidal ideation. Charge Nurse sent RI #335 to the ER and transported by HEMSI.
- Resident #335 returned from the hospital by HEMSI with no new orders. Labs were drawn at the ER. Per ER records resident denied any complaints, denied suicidality and homicidal ideations.
- Resident's #334 and #335 were separated by the CNA.
- Resident #334 was assessed by the Charge Nurse, with no injuries noted.
- The Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. Resident #334 was assessed by the Nurse with no negative findings.
- Resident #335 was placed on one on one by the Charge Nurse until resident transferred to the hospital by HEMSI and ultimately discharged.
- Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident with no negative findings.
- Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse with no negative findings.
- Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events by the Administrator.
- Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone with no negative findings.
- Residents with a BIMS of 12 or less, a body audit and observation for abuse and behaviors was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse with no negative findings.
- Resident interviews using a Resident Psychosocial Health Questionnaire were conducted by Social Services Director with BIMS of 13 or greater to determine resident's mood, behaviors, and thoughts such as anxiety, agitation, depression, suicidal and homicidal ideations, with no new negative findings.
- Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335.
- Clinical Record Review was initiated and completed by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of allegations of potential/actual abuse, aggressive, distress, and combative behaviors, and suicidal and homicidal ideations, with no new unknown findings.
- Inservice was provided by the Assistant President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress and combative behaviors, and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed.
- The Staffing Coordinator was designated as responsible for ensuring staff are educated on abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors.
- Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors, and suicidal/homicidal ideation to all staff. Staff unavailable to receive education will not be permitted to work until the required education is completed. 73 out of 77 employees have been educated.
- Competency and validation questions were answered by staff currently working to ensure competency verbalized from education received.
- The Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress and combative behaviors, and suicidal/homicidal ideation. This communication binder is used as a communication tool for staff to note resident behaviors, new or changes. This communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine appropriate interventions.
- Regional Nurse Manager inserviced the DON, Staffing Coordinator and Risk Manager that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations.
- The DON, Staffing Coordinator, and Risk Manager in-serviced Nursing Staff that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.
- Adhoc QAPI was conducted to include Administrator, Director of Nursing, Senior President of Operations, Assistant President of Operations, Regional Nurse Manager, Assistant President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions.
- The Medical Director was notified of the immediate jeopardy citations by the Assistant President of Operations.
- A Root cause analysis was conducted by the Administrator, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services.
- QAPI meeting was conducted to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant President of Operations, Regional Nurse Manager, Medical Director, Assistant President of Clinical Operations, Senior President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined.
- Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideations under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services.
- Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, and combative behaviors, and Suicidal and Homicidal Ideations.
- The facility assessment plan was revised to include suicidal ideations.
- A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant President of Operations, Assistance President for Clinical, Senior President of Operations, and Regional Nurse Managers to discuss the corrective action plans to address the immediate concerns for F 600, F 740, F 741 and F 867 for Resident's #334 and #335 and all current residents in the facility have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations.
- This Behavior Communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine any new or changes in behaviors, intervention implementation and appropriateness and will be revised as necessary.
- Upon return from a transfer when ER deems resident appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a Resident Return from Transfer Behavior assessment will be conducted. This will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. For any resident discharged and readmitted a readmission assessment is already part of the readmission process and is completed to include an abuse and behavior section. Nursing Staff was educated that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide ordered psychology services for a resident with depression and anxiety. The resident’s record showed an order for psych eval and treatment, but there was no documentation of recent psych visits despite a note stating she saw psychology regularly. The resident reported frequent sadness, crying, thoughts about dying, and wanting to talk to a counselor. The SSD said she received the order but did not send the referral, and the DON said social services was responsible for processing psychology orders.
A resident with bipolar disorder, anxiety, and intellectual disability had persistent escalating behaviors including yelling, cursing, throwing objects, physical aggression, self-injury, threats, and sexually inappropriate actions. Despite repeated BH evaluations, 1:1 supervision, and a psychiatric hospitalization, the care plan interventions were not shown to be evaluated or revised in response to the ongoing behaviors, and the NHA could not provide evidence that the interdisciplinary team had reviewed their effectiveness.
A resident with schizoaffective disorder, MDD, and bipolar disorder became frustrated during medication pass when the routine was delayed and different from usual. The resident became verbally aggressive and charged toward the med room, but staff did not call Code Green when escalation began. A CMT then used a non-approved CPI technique by grabbing the resident by the collar and taking the resident to the ground, resulting in minor facial abrasions and complaints of ankle and toe pain.
Failure to provide behavioral health services for a resident with schizophrenia and moderate cognitive impairment. The resident was receiving multiple antipsychotic meds and had a care plan for agitation, anger, cursing, grabbing, hitting, and kicking. The resident struck another resident, sending both to the ED. A PASRR Level II review recommended case management and a neurocognitive eval, but the record showed no evidence these services were provided.
A resident with schizoaffective disorder, anxiety, severe cognitive impairment, and ongoing behavioral issues was not evaluated or treated by psych care despite a physician order for psych services. Staff observed refusals of care, pushing away the CNA, throwing items, and attempting to pull at his catheter, while the CNA said a snack was the easiest way to get him to cooperate. The psych PA said he never assessed the resident because of an issue with the order, and facility staff reported the referral process was sent but the resident still was not seen.
A resident with dementia, bipolar disorder, and schizophrenia repeatedly refused antipsychotic meds, including oral fluphenazine and later fluphenazine decanoate. Staff documented medication nonadherence, catatonic features such as withdrawal, intermittent mutism, and posturing, plus poor PO intake, weight loss, and UTI. The resident was later transferred to the hospital for altered mental status and agitation after the next of kin called 911.
Failure to Provide Ordered Psychology Services
Penalty
Summary
The facility failed to provide ordered behavioral health services for one resident with depression and anxiety. The resident’s MDS indicated she was cognitively intact, had no hallucinations or delusions, and was depressed with trouble falling asleep and poor appetite. Her medical record included an order for escitalopram for depression and a care plan directing staff to arrange psychology follow-up as indicated, discuss concerns and fears with the resident, and provide time and encouragement for her to express feelings. The resident’s care conference note stated she was cognitively intact, had mild signs and symptoms of depression, had no behaviors, and saw psychology on a regular basis. The resident’s EMR contained an order for psychology to evaluate and treat, but there was no documentation of psychology visits in the last 12 months, which conflicted with the social services note. During observation and interview, the resident stated she became sad very often, cried and could not stop crying, thought about dying, and wanted to talk to somebody or a counselor. The DON stated social services oversaw psychology orders, and the SSD stated the resident had previously received psychology services but was discharged in December 2024. The SSD also stated she received the psychology order but did not send the referral, and later stated she needed to obtain a new consent and send the referral because she was unaware the facility had in-house psychology visits.
Failure to Evaluate and Revise Behavioral Health Interventions
Penalty
Summary
The facility failed to implement, evaluate, and revise behavioral health interventions for a resident with bipolar disorder, anxiety, and intellectual disability who had a persistent and escalating pattern of behavioral symptoms. The resident’s annual MDS dated May 4, 2026, showed he was cognitively intact with a BIMS score of 15. The facility policy required behavioral health services as needed to support residents’ highest practicable physical, mental, and psychosocial well-being, with staff promoting dignity, autonomy, privacy, socialization, and safety. Clinical documentation showed repeated episodes of yelling, screaming, cursing, verbal aggression, physical aggression, throwing objects, destruction of property, threats toward staff, self-injurious behaviors, sexualized behaviors, refusal of care, and behaviors that disrupted other residents. The resident pulled a needle from his arm during a blood draw, spit at and cursed a phlebotomist, threw belongings into the hallway, became combative with care, threatened staff, threw utensils and other items, ripped equipment from the wall, and caused other residents to report fear of him. He also struck another resident in the leg with a highlighter, threatened to kill a nurse, distributed sexually inappropriate notes, threatened to kill staff, and required one-to-one observation and a 302 psychiatric commitment with hospital transfer after escalating aggression and self-harm statements. After returning from the hospital, the resident continued to display frequent and escalating behaviors despite the existing care plan interventions. Documentation showed ongoing yelling, cursing, throwing objects, spitting medications, striking himself, threatening staff, refusing care, and repeated need for behavioral health involvement and one-to-one supervision. The care plan identified risks related to self-harm, physical abuse, inappropriate sexual behavior, and rejection of care, and directed staff to allow self-soothing, monitor triggers, reapproach after agitation, and discourage throwing objects into the hallway. However, the record did not show that the interdisciplinary team evaluated whether those interventions were effective or revised the care plan in response to the resident’s changing behavioral needs. During interview, the NHA was unable to provide evidence that the team had evaluated the interventions or revised the behavioral care plan despite the persistent pattern of escalating behaviors.
Failure to Follow CPI During Resident Behavioral Escalation
Penalty
Summary
The facility failed to follow its CPI policy and behavioral health expectations for a resident with a history of aggression toward staff. The resident had diagnoses including schizoaffective disorder, major depressive disorder, and bipolar disorder, and the MDS showed the resident was cognitively intact but had physical behavioral symptoms directed toward others. The care plan identified negative behaviors such as charging people, seeking revenge, hitting, and tackling, and listed triggers including bullying, stealing, and loss of control. During morning medication administration, the resident became frustrated because the medication pass was slower than usual and different from the resident’s normal routine. The resident repeatedly demanded medications, became verbally aggressive, and approached the medication room doorway. Staff did not initiate a Code Green when the resident began escalating. Instead, the CMT told the resident he/she would document the medications as refused, which further upset the resident. The resident then yelled and charged at the medication room door. When the resident entered the medication room area and the situation escalated, the CMT used a non-approved technique by grabbing the resident by the collar and moving the resident to the ground. The resident sustained an abrasion to the right cheek and right eyebrow and complained of pain to the right ankle and big right toe. Witness statements and staff interviews described that the response did not follow approved CPI techniques and that Code Green procedures were not initiated early in the escalation.
Failure to Provide Behavioral Health Services for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure behavioral health services were provided to a resident with schizophrenia and moderate cognitive impairment, as shown by a BIMS score of 10 out of 15. The resident’s MAR showed treatment with multiple antipsychotic medications, including haloperidol, clozapine, and aripiprazole. The care plan identified impaired psychosocial well-being with behaviors requiring intervention, including agitation, anger, cursing, grabbing, hitting, and kicking, and listed interventions such as redirection, removal from the situation, meaningful activity, reapproach, and one-to-one supervision. A facility incident report showed the resident struck another resident on the left side of the face, and both residents were assessed and sent to the ED. The resident’s PASRR Level II review recommended case management and a neurocognitive evaluation, but the medical record showed no evidence that either a neurocognitive evaluation or mental health services were provided. A social services assistant stated that she and another assistant checked on the resident a couple of times a day, especially when the resident had behaviors, and confirmed the resident had not received a neurocognitive evaluation upon admission and did not receive case management services.
Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident with diagnoses including schizoaffective disorder, bipolar type, generalized anxiety disorder, restless and agitation, and a healing spinal compression fracture. The resident’s quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment, and documented verbal behavioral symptoms toward others and refusals of care. His care plan identified behavior problems such as throwing his foley bag, oxygen tubing, call light, and blankets on the floor, as well as resistance to care including refusing lab draws, medications, and showers at times. The resident also had a physician order for psych care to evaluate and treat related to schizoaffective disorder, bipolar type. During observation, he was awake and alert in his room and later resisted hands-on care, saying no, pushing the CNA’s hand away, throwing his call light, and attempting to pull on his indwelling catheter. The CNA stated these behaviors were typical and that a snack was the easiest way to get him to cooperate. Nursing staff were aware of his behaviors, and the resident was not receiving psychosocial services from the psych care team at the time of the survey. The psychological services PA stated he had never assessed the resident and had been unable to see him because of an unknown problem with the order. Facility staff reported that a referral had been sent and corrected orders were later provided, but the resident still had not been seen. The LVN stated the referral was written and sent through the system, after which nursing staff had no further role, while the Regional Compliance Nurse stated staff should notify the psych PA and that residents exhibiting behaviors should be seen. The facility policy stated residents would receive behavioral health services as needed to attain or maintain the highest practical physical, mental, and psychosocial well-being.
Failure to Provide Behavioral Health Care for a Resident With Medication Refusal and Catatonic Symptoms
Penalty
Summary
The facility failed to ensure a resident received necessary behavioral health care and services in accordance with the comprehensive assessment and plan of care. The resident had diagnoses including non-Alzheimer's dementia, bipolar disorder, and schizophrenia, and the annual assessment documented moderate cognitive impairment, loneliness or isolation at times, and routine antipsychotic use. The psychoactive medication care plan identified the resident as being at risk for side effects related to psychoactive medications and directed staff to administer medications as ordered, monitor behaviors and response to medications, and notify the physician if medications were refused. The resident repeatedly refused antipsychotic medication, including oral fluphenazine and later fluphenazine decanoate injections, with the medication administration records showing 144 refusals out of 178 doses from March through June. Psychiatric and medical notes documented medication nonadherence and catatonic features such as withdrawal, intermittent mutism, and posturing, along with decreased oral intake and impaired functioning from baseline. Nursing and provider notes also documented ongoing refusals of all medications, and the physician and nurse practitioner were made aware of the refusals on multiple occasions. The resident’s condition continued to decline, with documentation of urinary tract infection, poor oral intake, and weight loss, and the resident was transferred to the hospital after the next of kin called 911 for further evaluation. Hospital discharge paperwork documented admission for altered mental status, agitation, urinary tract infection, poor oral intake, and reported weight loss. The psychiatrist stated that holding the antipsychotic medication may have contributed to catatonia and that if they had known the injectable antipsychotic was not being taken regularly, the resident would have been sent to the hospital within a month to stabilize medication; the psychiatrist also stated there was no discussion with the interdisciplinary team about hospitalization for psychiatric stabilization.
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