Inappropriate Secured Unit Placement and Lack of Proper Documentation
Summary
The facility failed to ensure appropriate placement and interventions for a resident, leading to a deficiency in behavioral health services. The resident, who had Parkinson's Disease and dementia with agitation, was admitted to the facility for therapy and strengthening. Despite being cognitively intact and having a BIMS score of 14, the resident was placed in a secured unit without a clear clinical indication or proper authorization. This decision was based on verbal communication and assumptions rather than documented evidence or a formal order from the attending physician. The resident expressed frustration and confusion about being in the secured unit, which was not aligned with his cognitive status and personal capabilities. He was able to manage his finances and expressed a desire to leave the facility, indicating that he did not belong in the secured unit. The resident's family and physician were not adequately consulted about the placement, and there was a lack of proper documentation to justify the decision. The facility's staff, including the DON and LPN, acknowledged that the resident was independent and did not require the restrictions of a secured unit. The deficiency was further compounded by the facility's failure to secure the resident's environment properly. The resident was able to exit the facility through a window due to loose metal brackets, highlighting a lapse in safety measures. Interviews with staff revealed confusion and miscommunication regarding the resident's placement and the necessity of the secured unit. The facility's policy required a signed consent for secured unit placement, which was not appropriately obtained or documented, leading to the resident's inappropriate confinement and subsequent distress.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident admitted with a stroke diagnosis had an initially normal PHQ-9 and BIMS, but later developed tearfulness, frustration about not going home, repeated refusals of care, irritability, withdrawal, and sexualized behaviors toward a CNA. Staff interviews described the resident as not very expressive, sometimes tearful, and seeming to struggle with depression, while the RNCM stated there was no record of a depression assessment or mental health therapy being offered. The resident later stated feeling depressed and suicidal and wanting to go home.
A resident with severe cognitive impairment, Parkinson’s disease, and esophageal obstruction was on a pureed diet, but the care plan was not updated to address repeated attempts to obtain regular foods. The resident ate a granola bar from an unknown source, shared popcorn from another resident during an activity, and later grabbed pineapple from another resident’s tray. Each event led to coughing, emesis, inability to swallow, or hospitalization for esophageal impaction/obstruction and EGD treatment.
A resident with a history of depression and anxiety experienced increased distress due to constant yelling from other residents. Despite reporting frustrations, the facility failed to address the issue, leading to the resident's decreased social interaction and increased withdrawn and angry behaviors. Incomplete mood assessments and ineffective interventions contributed to the deficiency.
A resident with severe cognitive impairment exhibited ongoing verbal, physical, and sexually inappropriate behaviors, including aggression and refusal of care. Despite repeated documentation of these behaviors, staff did not assess or analyze the situation or attempt new interventions, and no psychiatric evaluation was scheduled, as confirmed by the DON.
A resident with PTSD was trapped in a malfunctioning elevator, triggering severe anxiety and PTSD symptoms. Despite the resident's request for psychological support, the facility failed to inform the physician or therapist and did not develop a care plan for the resident's mental health needs. The Nursing Home Administrator was aware of elevator issues but did not shut it down until after the incident.
A resident with rheumatoid arthritis and muscle weakness expressed multiple grievances, including medication issues and lack of showers, but did not receive necessary behavioral health services. Despite documented concerns and a desire to return home, the facility failed to follow up with social services. Staff interviews revealed a lack of adherence to reporting and documentation processes, highlighting deficiencies in addressing the resident's needs.
Failure to Address Resident Mood and Behavior Changes
Penalty
Summary
The facility failed to ensure that a resident did not develop patterns of decreased social interaction and increased withdrawn, angry, or depressive behaviors unless unavoidable. Resident 14 was admitted with diagnoses including cerebral infarction (stroke). The resident’s MDS completed in 9/2025 showed a BIMS score of 15 and a PHQ-9 score of 00, indicating the resident was cognitively intact and not depressed at that time. A 10/14/25 progress note documented that the resident was tearful, asked about therapy options after being discharged from PT for lack of progress, and expressed frustration about not being able to go home. The resident had previously been described as pleasant and cooperative, and a 10/15/25 note documented the resident declined a shower despite multiple staff attempts, with no prior declinations of care noted in the record. Subsequent progress notes documented continued changes in mood and behavior, including calling the mother believing discharge was scheduled, being tearful and upset about going home, being charted as alert for depression for 1 week, declining multiple showers or a bed bath, expressing sexualized feelings toward a female CNA, becoming irritable with staff, refusing bowel care, appearing unmotivated and avoiding eye contact, refusing to get out of bed, refusing independent exercise therapy, and later being tearful during a provider visit. On 12/29/2025, the resident stated feeling depressed and suicidal and wanting to go home, and stated staff had not been told about these feelings. During interviews, staff described the resident as not very expressive, needing frequent checks because the resident would not ask for care, and seeming to struggle with depression and sometimes being tearful. The RNCM stated there was no indication in the clinical record that the resident had been assessed for depression or offered mental health therapy, while the SSA stated therapy had been discussed and declined, but no practitioner evaluation for depression had been requested.
Failure to monitor repeated access to non-approved foods
Penalty
Summary
The facility failed to monitor and provide ongoing assessment of whether care approaches were meeting the needs and behaviors of a resident with severe cognitive impairment and a pureed diet. The resident had diagnoses including Parkinson’s disease and esophageal obstruction, and the quarterly MDS assessed a BIMS score of 0 out of 15. The resident’s comprehensive care plan addressed behaviors such as rejected care and services, refused meals, hallucinations, false allegations, anxiety, irritability, anger, picking at skin, and wrapping rubber bands around a stump, but it was not updated to address the resident’s repeated attempts to obtain and eat regular foods that were not allowed on the ordered pureed diet. On 08/09/2025, the resident obtained and began eating a granola bar from an unknown source while in bed. The RN removed the granola bar, told the resident it was not appropriate for the ordered diet, and notified the NP and the POA. Later that day, the resident developed blood around the gastrostomy tube site and was sent to the ER. The hospital discharge summary documented food impaction of the esophagus, esophageal stenosis, dementia, Parkinson’s disease, esophageal stent, and PEG tube replacement, and stated the CT scan showed impaction of the esophageal stricture reportedly due to access to granola bars not included in the prescribed diet. On 09/19/2025, during an activity in the dining room, another resident shared popcorn with the resident. Staff observed the resident with popcorn, and he began coughing. He was taken to the nurses’ station, had emesis, could not swallow water, and was sent to the ER. The hospital discharge summary documented admission for esophageal stricture and an EGD with dilation of the stricture, and the resident returned to the facility tolerating a pureed diet. On 10/16/2025, the resident grabbed pineapple from another resident’s tray in the dining room. He later returned to the hospital with vomiting and inability to swallow liquids, and the discharge summary documented esophageal obstruction, chronic dysphagia, chronic esophageal strictures, GERD, and EGD with removal of food from the upper esophagus and dilation of the esophagus.
Failure to Address Resident's Psychosocial Distress Due to Environmental Noise
Penalty
Summary
The facility failed to adequately assess and address a resident's expressions of distress, leading to decreased social interaction and increased withdrawn, angry, and depressive behaviors. The resident, a cognitively intact female with a history of major depression and anxiety disorder, expressed frustration due to the constant yelling of other residents in her hall. Despite reporting these frustrations to staff, no effective measures were taken to alleviate the situation, resulting in the resident's increased distress and uncharacteristic behavior. Observations revealed that the resident preferred to keep her door closed and use ear buds to block out the noise, yet she continued to experience frustration and anxiety. The facility's psychiatric consults noted the resident's sleep disturbances and recommended non-pharmaceutical interventions, but these were not effectively implemented. The resident's mood assessments were incomplete, further indicating a lack of comprehensive evaluation and intervention by the facility. Interviews with staff confirmed that the issue of residents yelling was well-known, yet no grievance forms were completed, and the problem persisted. The facility's decision to place several residents who frequently yelled in the same area exacerbated the situation, affecting the resident's mental well-being. The Social Service Director acknowledged the resident's recent behavioral changes, which were uncharacteristic and linked to the ongoing disturbances.
Plan Of Correction
Element 1: Resident 52 no longer resides in facility. Element 2: Residents on C hall with a Brief Interview of Mental Status of 9 or greater had a Patient Health Questionnaire-9 completed to ensure residents have had no expressions of distress, developed decreased social interaction, increased withdrawal, anger, and depressive behaviors. Any changes in Patient Health Questionnaire-9 have had referrals made to psychology services. Element 3: CNAs and Nurses were re-educated on proper documentation of behaviors including depression, agitation, withdrawal, distress, anger, etc. Interdisciplinary Team will review clinical documentation M-F to ensure any changes in behaviors are followed up on. Element 4: The Administrator will complete an audit reviewing 6 residents per week to evaluate Patient Health Questionnaire-9 scores and ensure appropriate interventions are in place if eligible. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.
Failure to Assess and Intervene for Escalating Resident Behaviors
Penalty
Summary
The facility failed to monitor, assess, and analyze a resident's escalating behavioral issues, including verbal and physical aggression as well as inappropriate sexual behaviors. The resident, who was severely cognitively impaired and required staff assistance for daily care, exhibited a pattern of combative and aggressive actions, such as refusing care and medications, yelling at staff, threatening to hit staff, wandering into other residents' rooms, and making inappropriate sexual comments. These behaviors were documented repeatedly in nursing notes over a two-month period. Despite the ongoing and increasing nature of these behaviors, there was no documented evidence that the facility assessed or analyzed the resident's behaviors or attempted new interventions to address them. Additionally, although the resident's antipsychotic medication was discontinued and later restarted, no psychiatric evaluation or treatment was scheduled. The Director of Nursing confirmed that the resident was in need of psychiatric evaluation, but none had been arranged as of the time of the survey.
Failure to Address PTSD and Develop Care Plan After Elevator Incident
Penalty
Summary
The facility failed to develop a plan of care for a resident diagnosed with PTSD, anxiety, and depression, following a distressing incident where the resident was trapped in an elevator. The resident, who had a history of PTSD, hypertension, depression, and a nonhealing diabetic foot ulcer, experienced a traumatic event when the elevator malfunctioned, causing severe anxiety and triggering PTSD symptoms. Despite the resident's request for psychological support, there was no documented evidence that the facility informed the physician or therapist about the incident or the resident's request for therapy. Interviews with staff confirmed the resident's distress and the lack of immediate psychological intervention. The Nursing Home Administrator was aware of issues with the elevator prior to the incident but did not take action to shut it down until after the resident was trapped. The facility's failure to address the resident's mental health needs and the lack of a care plan for the resident's PTSD and related conditions contributed to the deficiency.
Plan Of Correction
1. Resident R220 was seen by psychological services. 2. Residents with PTSD will be seen by psychological services to ensure proper plan is in place. 3. Staff will be educated on the components of this regulation with an emphasis on managing behavioral difficulties appropriately. 4. Audits of 5 residents with PTSD will ensure they have been seen by psychiatric services 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Failure to Provide Behavioral Health Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health services despite the resident expressing multiple concerns and grievances. The resident, who was admitted with diagnoses including rheumatoid arthritis and muscle weakness, had a BIMS score indicating no cognitive impairment. Despite being described as pleasant and cooperative, the resident reported issues such as not receiving the correct medication, not having a shower since admission, and feeling frustrated and distrustful of the aides. These concerns were documented in various progress notes, yet there was no evidence of a referral for behavioral health or social services. The resident expressed a desire to return home, citing dissatisfaction with the care received, including issues with medication and therapy. The resident also reported feeling upset about the lack of attention from staff, such as an aide being on the phone during meal service. Additionally, the resident was worried about housing issues and the potential theft of a walker. Despite these documented grievances, the facility did not follow up with social services or behavioral health services to address the resident's concerns. Interviews with facility staff revealed a lack of action in response to the resident's grievances. Staff members described processes for reporting abuse and psychological impacts of isolation, but there was no indication that these processes were followed in this case. The facility's policies on abuse, neglect, and promoting resident dignity were not adhered to, as there was no documentation of interviews or care plan revisions. The medical director acknowledged the need for better documentation and follow-up on complaints, indicating a gap in the facility's response to the resident's needs.
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