Failure to Manage Resident's Psychiatric Needs Leads to Assault
Summary
The facility failed to ensure that a resident with a history of schizophrenia and aggressive, inappropriate sexual behaviors was properly evaluated and treated upon admission. The resident, who had been receiving Clozapine for disorganized thoughts and aggressive behavior at a previous facility, was not assessed by a psychiatrist or prescribed the necessary medications upon admission to the current facility. This oversight led to the resident not receiving any treatment for his schizophrenia since his admission. As a result of the facility's inaction, the resident sexually assaulted another resident twice. The first incident was witnessed by a Certified Nursing Assistant (CNA), who separated the residents but failed to maintain supervision. Shortly after, the resident assaulted the same individual again, which was witnessed by another CNA. The assaulted resident had severe cognitive impairments and was dependent on staff for daily activities, making them particularly vulnerable. The facility's failure to review the resident's psychiatric history and medication needs, as well as the lack of immediate and appropriate intervention by staff, resulted in the resident's aggressive behaviors going unchecked. This placed other residents at risk and led to the sexual assault of a vulnerable resident. The facility's Director of Nursing admitted to overlooking the resident's psychiatric history and failing to ensure the resident received the necessary behavioral care and services.
Removal Plan
- Ensure all residents are free from abuse through training addressing the critical elements of identifying all categories of abuse and the procedures for reporting abuse.
- Resident was discharged from the facility and sent to a General Acute Care Hospital for psychiatric evaluation and treatment.
- Resident was transferred to a General Acute Care Hospital for evaluation and returned to the facility.
- Upon Resident's return, the Social Services Director began monitoring Resident for emotional distress. Resident was seen by a psychologist and psychiatrist.
- The Social Services Director interviewed all cognitively aware residents and inquired if they have experienced abuse or know of any abuse in the facility. Staff were interviewed regarding residents who were not able to be interviewed.
- All residents with psychiatric diagnoses admitted will be reviewed by the interdisciplinary team for their psychiatric and behavioral needs, including their medication regimen and/or need for psychiatric consultation.
- Any residents admitted will be assessed by the interdisciplinary team for their medical, physical, and psychological needs and care planned accordingly.
- Staff training on abuse prohibition will consist of abuse prevention, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond.
- The Director of Nursing, the Director of Staff Development, and/or Clinical Resources will in-service and educate licensed nurses to review admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned.
- The Administrator, the Director of Nursing, the Director of Staff Development or Clinical Resources will in-service and educate facility staff on the immediate action required during an alleged abuse situation.
- Education and training for staff on leave, vacation, per diem or registry status will be completed prior to the start of their working shift.
- The facility Medical Director was notified of the Immediate Jeopardy and will continue to assist the facility to meet the needs of the Residents.
- Prior to the Quality Assurance Performance Improvement meeting, all training and education which includes abuse, review of admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned, separating residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision to keep a resident safe from any further alleged abuse, and all resident interviews regarding any alleged abuse, will be completed.
- This Immediate Jeopardy Removal Plan will be reviewed at the next scheduled QAPI Committee Meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who suffered a traumatic resident-to-resident assault with a head injury and intracranial bleeding continued to report fear that the other resident would enter her room again. The record showed the other resident had repeated room-entry and agitation issues, but there was no documentation of psychosocial monitoring for the affected resident after the incident, despite later anxiety and agitation noted in the chart.
A resident with TBI, stroke-related deficits, depression, and anxiety repeatedly displayed verbal aggression toward a former roommate, including threats, profanity, and blocking the other resident’s path in common areas. Although staff separated the residents at times and the resident was later sent to the ED for an aggressive reaction, the care plan did not identify the ongoing aggression toward the specific resident or include targeted interventions, and staff interviews showed inconsistent awareness and poor communication about the conflict.
Failure to Monitor and Document Behavioral Symptoms: A resident with dementia with agitation and Alzheimer’s disease had physician-ordered monitoring for agitated behaviors and non-pharmacological interventions, but staff did not consistently document his behaviors or interventions. The resident had a history of choking his wife, later misidentified and attempted to kiss a female resident, and entered another resident’s room where he allegedly kissed or attempted to kiss one resident and threatened the other. He was also observed unsupervised, walking the halls and interacting with other residents, and the DON confirmed the care plan and MD orders were not implemented for behavioral health management.
A resident with stroke, anxiety, and mild neurocognitive disorder with behavioral disturbance had escalating verbal aggression, threats, refusal of care, and statements suggesting paranoid or delusional thoughts. The care plan addressed verbal aggression, but the record showed worsening depression-related findings, repeated behavioral incidents, refusal of behavioral health services and other care, and recent self-mutilating behaviors. The DON acknowledged that a significant change PASARR probably should have been completed, while the SSD reported limited involvement beyond BIMS and PHQ screening.
Failure to provide appropriate behavioral health monitoring and services: two residents with significant psychiatric histories and behavioral care plans did not receive adequate oversight or timely provider notification. One resident assaulted a roommate, then was left with one-on-one monitoring that was not maintained within line of sight while the resident yelled, pounded on walls, and became increasingly agitated; another resident had repeated behavioral emergencies and aggression after an antipsychotic dose reduction, but staff did not adequately monitor the resident or promptly notify the psychiatric provider.
Delayed Psychiatric Services: A resident with neurocognitive disorder with Lewy bodies, psychosis, and anxiety had psych consult orders that were not completed in a timely manner. Staff reported the delay was related to obtaining consent from the wife, limited psych NP availability, vacation coverage gaps, and caseload prioritization, resulting in the resident not being seen by psych until well after the orders were placed.
Failure to Address Psychosocial Impact After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a resident who experienced a traumatic event received appropriate treatment and services after a resident-to-resident physical abuse incident that resulted in major injury. Resident #65, who was cognitively intact with a BIMS of 14, was found lying on the floor in the doorway to her room with bleeding from a head wound after Resident #42 was found in her room holding her iPad and a struggle occurred. Resident #65 was transferred to the ED, where trauma imaging showed an acute medial right frontal lobe multifocal subarachnoid hemorrhage with parafalcine and right tentorium subdural hematoma measuring up to 5 mm, with no midline shift. After the incident, Resident #65 reported ongoing fear that Resident #42 would enter her room again, stating staff took the other resident away when she came in and that she was afraid and had to watch her. The record showed Resident #42 had a pattern of entering other residents’ rooms, agitation, combativeness, and interpersonal conflict, with CPS recommending redirection, re-orientation, structured environment, and limited overstimulation. Resident #65’s notes documented denial of needs on one date and denial of psychosocial needs at a later social work visit, and no additional documentation of psychosocial monitoring was found. The resident later had increased anxiety with Buspar ordered and was verbally agitated with staff, while the care plan only addressed the subdural hemorrhage and monitoring for mental status changes and abnormal findings.
Failure to Address Ongoing Verbal Aggression Between Two Residents
Penalty
Summary
The facility failed to ensure that a resident with a traumatic brain injury, stroke-related deficits, depression, anxiety, and intermittent irritability received appropriate treatment and services to support mental and psychosocial well-being. The resident had a history of becoming verbally aggressive toward a former roommate, including threatening to beat the roommate and using profanity toward the roommate in common areas. The resident’s care plan identified general irritability, depression, anxiety, and the need to observe mood and notify the physician of changes, but it did not identify the resident’s repeated verbally aggressive behaviors toward the former roommate or include specific interventions to address those behaviors. After an initial incident in which the resident threatened the former roommate in the dining room, staff separated the residents for the rest of the day, but the care plan was not updated to reflect the behavior or targeted interventions. A later behavior management evaluation documented another episode in which the resident expressed an intent to harm the other resident, and staff notified the RN and the resident’s family. The resident was later sent to the emergency department after another confrontation involving the former roommate, where the resident had blocked the other resident’s path, used profanity, and was diagnosed with an aggressive reaction and given hydroxyzine. The resident continued to display verbally aggressive behavior toward the former roommate after these events, including cursing at the resident in the dayroom and refusing to move away when directed by staff. The care plan remained general and continued to describe irritability, staring triggers, limited abilities, poor safety awareness, and impulsivity, but still did not identify the ongoing aggression toward the former roommate or specific interventions for that behavior. Staff interviews reflected inconsistent awareness of the ongoing conflict, with some staff stating there were no further issues and others stating the problem was ongoing and communication between shifts was poor. The physician and family member both described the residents as not getting along, and the physician stated staff should monitor them like other residents, while the facility administrator stated she would not expect the care plan to contain specific interventions related to the other resident.
Failure to Monitor and Document Behavioral Symptoms
Penalty
Summary
The facility failed to implement physician-ordered monitoring and documentation of agitated behaviors and non-pharmacological interventions for a resident with dementia with agitation, Alzheimer’s disease, and a history of colon and prostate cancer. The resident’s MDS showed cognitive impairment, and a physician’s order dated February 18, 2026 directed staff to monitor and document agitated behaviors and attempted interventions every day and on every shift. The care plan also included interventions to engage the resident in structured activities and to observe, document, and report behavioral changes to the physician. Facility documentation showed that after the resident was admitted following an incident in which he choked his wife at home, he later misidentified a female resident as his wife, attempted to kiss her, and followed her until staff intervened, which led to his move to another floor. On July 16, 2026, he entered the room of two residents without invitation, allegedly kissed or attempted to kiss one resident without consent, and threatened the other resident with bodily harm when objected to. Review of documentation from June 27, 2026 through July 27, 2026 showed no evidence that his behavior was monitored and documented for 22 of 30 days, including July 16, 2026. During observation on July 27, 2026, he was seen unsupervised interacting with other residents, walking the halls independently, and sitting alone at a window, and the DON confirmed that the physician’s orders and care plan were not implemented for behavioral health management.
Failure to Provide Behavioral Health Services for Resident With Escalating Behavioral and Psychosocial Needs
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to a resident with diagnoses including stroke, generalized anxiety disorder, and mild neurocognitive disorder with behavioral disturbance, in order to assist him in achieving his highest practicable mental well-being. The facility policy required behavioral health care and medically-related social services based on comprehensive assessment and care planning, with behavior tracking and interdisciplinary assessment when behaviors or mood changes posed concerns. The resident’s care plan identified verbal aggression related to frustration with his family, with an intervention to monitor behavior episodes and determine underlying causes, but the record showed escalating behavioral concerns without documentation of a significant change PASARR assessment. The resident’s annual MDS documented little interest in doing anything and feeling down, depressed, or hopeless almost daily, along with rejection of care for one to three days out of seven and worsening behaviors since the prior assessment. Progress notes documented repeated verbal aggression, profanity, threats toward a visitor, and statements that staff were covering things up. He also made statements suggesting paranoid or delusional thoughts, including saying a nurse put something in his water and accusing staff of lying and drug use. The record also reflected refusal of medications, behavioral health services, insulin, and at times dialysis, along with recent documentation of self-mutilating behaviors. During interviews, the DON stated the resident had made other comments about dependent residents and had recent self-mutilating behaviors. The SSD stated she was not really involved in behavior management beyond BIMS and PHQ screening and described the resident as acting out more since returning from maternity leave. The Administrator stated the resident was aggressive, that the facility had tried counseling and family involvement, and that he had burned too many bridges. In a follow-up interview, the DON acknowledged that a significant change PASARR probably should have been completed and stated the staff were not documenting the delusions themselves, while also noting that the resident’s behaviors and self-mutilating behaviors had increased.
Failure to Provide Appropriate Behavioral Health Monitoring and Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents with mental disorders and behavioral health needs. One resident had diagnoses including bipolar disorder with psychotic features, schizoaffective disorder, depression, a history of substance abuse, prior suicide attempts, poor insight and judgment, impulsive behavior, and a care plan calling for close monitoring, coping skills, and notification of the physician for new behaviors. After a conflict with a roommate, the resident assaulted the roommate during a room move, causing the roommate to sustain an abrasion to the lip, scratches to the chest, and red marks around the neck. The resident was placed on one-on-one monitoring after the altercation, but staff were observed outside the room with the door closed while the resident yelled, pounded on the walls, and used profanity, and one assigned staff member was later found asleep on the floor outside the room. The same resident’s care plan and facility policies called for close behavioral monitoring, use of coping skills, de-escalation, and physician notification for behavioral changes. However, staff did not adequately monitor the resident when behaviors escalated, did not keep the resident within line of sight as required by the monitoring plan, and did not timely notify the psychiatric provider when the resident was yelling, hitting the walls, and displaying increased agitation. Interviews showed staff were unsure how far the behaviors had to go before calling a Code Green, and one staff member stated he or she opened the door only about every hour. The psychiatric provider stated staff should not have left the resident alone in the room with the door closed while the resident was yelling and hitting the wall. A second resident had a history of chronic mental illness, suicidal ideation, aggressive behavior, impaired judgment, impaired impulse control, and medication non-compliance. After a psychiatric medication reduction, the resident had several behavioral emergencies, aggressive behaviors, and an attempted assault on another resident, during which the resident injured an ankle and fell. The record showed the psychiatric provider expected close monitoring for recurrence of mood swings, irritability, insomnia, anxiety, psychosis, behavior changes, and safety concerns, but the facility did not adequately monitor the resident or timely notify the psychiatric provider when the resident continued to have behavioral emergencies and aggression.
Delayed Psychiatric Services
Penalty
Summary
The facility failed to ensure psychiatric services were provided timely and according to orders for one resident with neurocognitive disorder with Lewy bodies, psychosis, and anxiety. The resident’s quarterly MDS showed severely impaired cognition, dependence for all ADLs, and bowel and bladder incontinence. The medical record showed orders for psych services on 04/10/26 and again on 05/03/26, but the resident was not seen by psych until 06/28/26. The delay was discussed in interviews with facility staff. The DON stated the delay was related to obtaining consent from the wife and confirmed the psych consult orders. SSD stated verbal consent from the wife was not received until the care conference on 05/25/26 and was unsure why psych did not see the resident sooner after that. SSD also stated the psych NP only comes to the facility every two weeks and was on vacation with no coverage. The psych NP acknowledged awareness that the resident was not seen for approximately one month after consent to treat was received and stated new referrals are sometimes pushed back based on caseload.
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