Failure to Monitor and Respond to Resident's Behavioral Health Needs
Summary
The facility failed to adequately monitor, document, and respond to the behaviors of a resident diagnosed with Parkinsonism, hallucinations, pneumonia, and acute respiratory failure. The resident, who was noted to have moderate cognitive impairment, exhibited aggressive behaviors that were not documented in the care plan. The care plan only included medication administration for hallucinations and anxiety, with no further interventions listed. Over a period of three days, the resident displayed aggressive behaviors, including attempting to hit others with a wheelchair, grabbing a nurse's necklace, and resisting care from CNAs. These incidents were not properly documented or addressed in the resident's care plan. Staff intervened by administering Haldol injections, but there was a lack of consistent non-pharmacologic interventions or individualized care strategies as per the facility's policy. Interviews with staff revealed confusion and a lack of clear protocol in handling the resident's behaviors. The Director of Nursing acknowledged the resident's recent increase in agitation and the need for staff to intervene when the resident posed a danger to themselves or others. However, there was a lack of awareness about the resident's injury during the incident, and staff actions may have exacerbated the resident's agitation. The facility's policy emphasized individualized interventions and non-pharmacologic approaches, which were not adequately implemented in this case.
Penalty
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A resident with Alzheimer's disease, personality disorder, major depressive disorder, and a known history of suicide attempts, including use of a garbage bag over the head, was admitted from a psychiatric hospital and assessed as cognitively intact but needing hands-on ADL assistance. Despite this history, the care plan contained only general behavioral strategies such as medication administration, redirection, supportive approaches, environmental calming, and behavior monitoring, without specific, measurable interventions like enhanced supervision or environmental safety precautions. A CNA later found the resident with a plastic bag over the head and face while preparing for dinner; the bag was removed and nursing was notified. On assessment, the resident voiced active suicidal ideation and a plan to attempt self-harm if left unsupervised, while the DON acknowledged the care plan lacked measurable interventions to address the resident’s suicidal ideation and behaviors, contrary to facility policy requiring comprehensive, person-centered care plans.
Multiple residents with substance use disorders engaged in ongoing illicit drug and alcohol use within the facility, including use of methamphetamine, cocaine, marijuana, and alcohol. Despite repeated positive drug screens, observed drug paraphernalia, and admissions of use, the facility did not implement specific interventions or update care plans to address illicit substance use. Staff and administrators confirmed that drug access was a common problem and that the facility lacked effective policies and actions to address substance abuse.
A resident with complex behavioral health and pain management needs did not receive scheduled medications in a timely manner after requesting them during the night. The assigned RN, citing concerns about the resident's agitated behavior, did not administer the medications or seek assistance from other available nurses, resulting in a delay of care and unmanaged pain. Facility policies and individualized care plans were not followed, as confirmed by staff interviews and documentation review.
A resident with a history of substance use disorder and multiple behavioral health needs did not receive appropriate assessment, care planning, or interventions to address ongoing substance use and related behaviors. Staff observed drug paraphernalia, erratic behavior, and frequent visitors suspected of bringing illicit substances, but the care plan was not updated and specific interventions were not implemented. The lack of coordinated response and documentation led to neglect of the resident’s mental and psychosocial well-being.
A resident with a history of sexually inappropriate behaviors and multiple psychiatric diagnoses did not receive appropriate behavioral health interventions prior to an incident involving inappropriate sexual contact with another resident. Although the care plan listed several interventions, staff interviews revealed that preventive measures were not in place before the event, and there was a lack of documentation and individualized strategies addressing the resident's behavioral risks.
A resident with major depressive disorder, PTSD, and anxiety disorder, who was cognitively intact, did not receive ongoing psychiatric evaluation and treatment as ordered. The last psychiatric service was provided several months prior, despite a current physician order, and this lapse was confirmed by the DON. Facility policy requires individualized behavioral health care, which was not provided in this instance.
Failure to Implement Individualized Behavioral Health Interventions for Suicidal Resident
Penalty
Summary
The facility failed to ensure individualized behavioral health interventions were implemented to meet a resident's mental health needs and prevent suicidal ideation with a suicide attempt. The resident was admitted with Alzheimer's disease, personality disorder, and major depressive disorder, and had been transferred from an assisted living facility to a psychiatric hospital following a prior suicide attempt involving placing a garbage bag over his head. On admission, the resident was cognitively intact and required hands-on assistance for activities of daily living. Despite this history, the care plan in place prior to the incident only included general behavioral approaches such as medication administration as ordered, redirection, non-judgmental support, environmental calming strategies, and monitoring and documentation of behaviors. On one occasion, the resident's assigned CNA observed the resident with a plastic bag placed over his head and face while staff were preparing to escort him to dinner. The CNA immediately removed the bag and notified nursing. Upon assessment, the resident expressed active suicidal ideation, stating that he did not want to be there, could not go on like that, and that he would attempt self-harm again if left unsupervised, also stating he should have done it later in the night. The guardian later reported a history of similar behaviors at previous facilities. The DON confirmed that the care plan did not include measurable interventions to address the resident's suicidal ideations and behaviors prior to this event, and the facility’s comprehensive care plan policy required measurable objectives and timeframes to meet residents’ mental and psychosocial needs identified in the assessment.
Failure to Provide Safe Environment and Effective Substance Abuse Program
Penalty
Summary
The facility failed to provide a safe environment free from drugs and alcohol and did not have an effective substance abuse program, as evidenced by multiple residents engaging in ongoing illicit drug and alcohol use while residing in the facility. Several residents with histories of substance use disorders, including opioid dependence, cocaine abuse, and alcohol abuse, were repeatedly found to be using illicit substances such as methamphetamine, cocaine, marijuana, and alcohol. Despite positive drug screens, observed drug paraphernalia, and admissions of ongoing use, the facility did not implement specific interventions to prevent or reduce illicit drug use, nor did it update care plans to address these issues. Staff interviews confirmed that drug access was a common problem and that the facility was not taking adequate action to address it. In one case, a resident with a history of opioid dependence and major depressive disorder tested positive for multiple illicit substances on several occasions, including methamphetamine, cocaine, and marijuana, without corresponding prescriptions. The resident's care plan lacked interventions specific to illicit drug use, and staff reported finding drug paraphernalia in the resident's room. The facility's behavioral health specialists stated that their recommendations for interventions were not implemented, and the administrator confirmed there was no policy addressing confirmed illicit substance use among residents. The facility's only response to suspected drug use was to notify the physician, as per their outdated policy. Other residents were also involved in incidents of drug use and related behaviors. Two residents sharing a room were found with an unknown visitor in possession of drugs, and one was observed performing sexual acts in exchange for substances. The facility failed to follow its own abuse and exploitation policies in response to this incident. Another resident with a history of alcohol and cocaine abuse was repeatedly found intoxicated, involved in altercations, and observed using marijuana in the facility, with no documented follow-up or interventions by staff. Interviews with staff and administrators confirmed a lack of cohesive care and policy regarding substance abuse, and that the facility had not taken effective steps to address the ongoing drug problem.
Failure to Provide Timely Behavioral Health and Pain Management Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan to support the behavioral health care needs of a resident with multiple psychiatric and physical diagnoses, including borderline personality disorder, PTSD, generalized anxiety disorder, severe morbid obesity, and chronic pain conditions. The resident had documented care plans addressing pain management, behavioral symptoms, aggressive behaviors, and psychiatric/mood issues, with specific interventions such as timely medication administration, emotional support, and strategies to minimize behavioral triggers. Despite these plans, the resident did not receive scheduled medications at the prescribed time after requesting them during the night, resulting in a delay of care. On the night in question, the resident requested her scheduled medications at 4:00 A.M., but the assigned RN was on break. Upon returning, the RN did not attempt to administer the medications or seek assistance from other available nurses, despite the presence of additional licensed staff on duty. The RN reported feeling unsafe due to the resident's agitated and hostile behavior, which included yelling and making derogatory remarks. Instead of following up with the physician or nurse practitioner regarding the late medication request, the RN only contacted facility management via text and did not receive a timely response. The resident ultimately did not receive her medications until several hours later, after experiencing significant pain. Interviews and documentation confirmed that other nurses could have administered the medications, and that the RN's failure to do so was not in accordance with facility policy or standard nursing practice. The facility's medication administration policy required medications to be given as ordered, and the behavioral assessment policy emphasized individualized interventions to address residents' needs. The incident was substantiated by medical record review, staff interviews, and disciplinary action taken against the RN for failing to provide necessary care.
Failure to Provide Behavioral Health Care for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a documented history of substance use disorder, resulting in neglect of the resident’s mental and psychosocial well-being. The resident, who had multiple diagnoses including paraplegia, anxiety disorder, depression, and chronic pain syndrome, was admitted with a known history of drug abuse, including the use of marijuana, methamphetamines, and cocaine. Despite this, the facility did not include substance use disorder in the resident’s diagnosis list or care plan, nor did it address his history of homelessness or trauma related to his accident and loss of his parents. The care plan lacked any mention of substance use triggers, interventions for substance use, or actions to take when the resident returned to the facility with altered mental status. Throughout the resident’s stay, there were multiple documented incidents of suspected substance use, including episodes where the resident returned to the facility with altered mental status, dilated pupils, lethargy, and abnormal behavior. Staff observed drug paraphernalia in the resident’s room, such as rolled-up dollar bills and pipes, and noted the presence of visitors at odd hours who were suspected of bringing in illicit substances. Despite these observations, the facility did not update the care plan to address substance use, did not consistently monitor or test for drug use, and failed to implement specific interventions to manage the resident’s behavioral health needs. Orders for naloxone (Narcan) and monitoring for adverse effects from substance use were absent, and staff responses were limited to holding narcotic medications and requesting drug screens, which the resident often refused. Interviews with staff revealed a lack of coordinated response and documentation regarding the resident’s substance use and related behaviors. The CNP acknowledged that the diagnosis of drug abuse should have been retained and that conversations about substance use disorder treatment were not documented. The DON confirmed that no care plan updates were made following a significant increase in the resident’s depression score. Staff expressed concerns about their safety and the impact of the resident’s behaviors on other residents and staff, but there was no evidence of supervision or restriction of visitors who may have contributed to the resident’s substance use. The facility’s failure to assess, care plan, and intervene appropriately for the resident’s behavioral health and substance use needs resulted in neglect as defined by facility policy.
Failure to Implement Behavioral Health Interventions for Resident with Sexual Behaviors
Penalty
Summary
The facility failed to implement appropriate behavioral health care and interventions for a resident with a complex medical and psychiatric history, including anoxic brain damage, dementia, bipolar disorder, major depressive disorder, PTSD, and substance abuse. The resident had a documented history of sexually inappropriate behaviors, and the care plan included interventions such as medication administration, behavioral health involvement as needed, monitoring for wandering, education on safe practices, and immediate removal from situations with 1:1 supervision when necessary. Despite these interventions being listed, staff interviews revealed that preventive measures were not in place prior to an incident where the resident engaged in inappropriate sexual behavior with another resident. Staff were unsure who witnessed the incident, and there was a lack of clarity regarding the implementation of preventive strategies before the event occurred. Following the incident, the resident was placed on 1:1 supervision for a short period and then on 15-minute checks, but no alternative or individualized behavioral interventions were documented prior to moving the resident to another unit. Psychosocial assessments for the involved residents were completed verbally but not documented at the time, and witness statements were used retrospectively for documentation. The deficiency was identified based on the lack of documented and implemented behavioral health interventions prior to the incident, as well as insufficient preventive measures to address the resident's known behavioral risks.
Failure to Provide Required Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to one resident with diagnoses of major depressive disorder, post-traumatic stress disorder, and anxiety disorder. The resident was cognitively intact and had a physician's order for psychiatric evaluation and treatment. Although the resident had been receiving psychiatric services for these conditions, the last documented service was provided on 05/07/24, despite a current order for ongoing evaluation and treatment. The Director of Nursing confirmed that no further psychiatric services had been provided since that date. Facility policy requires individualized care to support residents' physical, functional, and psychosocial needs, but this was not followed in this case.
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