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 with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with Alzheimer’s disease, anxiety, depression, and significant cognitive impairment expressed suicidal ideation to a volunteer, stating she had nothing to live for and wanted to kill herself. The resident’s care plan required immediate supervisor notification and redirection for suicidal comments, and facility policy required immediate reporting to the nurse supervisor, continuous supervision, completion of a suicide risk assessment, provider notification, and documentation. The volunteer documented the statement on a 1:1 visit log and verbally reported it to staff on an adjacent unit, but nursing staff on the resident’s unit were unaware of the incident, the Life Enrichment Specialist read the log days later and did not report it, and no further assessment, provider notification, or documentation of follow-up occurred.
A resident with schizoaffective disorder, PTSD, substance use history, and prior suicidal ideation had care-planned coping mechanisms that included watching calming TV programs and gaming. After staff removed items with cords, including the TV and gaming system, the resident was placed on 1:1 observation but was not provided access to the TV despite repeatedly requesting it as a coping tool. The assigned staff member had no prior 1:1 experience and focused only on physical supervision, while other team members were unaware of the resident’s escalating distress and requests. The resident became increasingly agitated, overturned carts, broke a window, and used a glass shard to cut the forearm, requiring ED and psychiatric care. Following the resident’s return, staff failed to thoroughly remove remaining glass shards from the room, allowing the resident to find and reuse shards on multiple occasions to cut the same forearm while alone. Although the care plan was updated to reflect high suicide risk and called for a written safety plan and specific self-harm interventions, the record showed no evidence that a written safety plan was developed with the resident, demonstrating a failure to implement person-centered behavioral health services and maintain a safe environment.
A resident with muscular dystrophy, intact cognition, and a PHQ-9 score indicating moderately severe depression requested talk therapy through the Ombudsman, who relayed the request to the SSD and then verbally to the DON. The DON later reported not becoming aware of the request until receiving an Ombudsman email weeks later, and the referral for psychological services was not initiated until much later, resulting in a 45-day delay before the resident was seen by a psychiatrist or psychologist. During this time, the resident reported auditory disturbances, insomnia, low energy, and was observed sitting quietly in activities with minimal interaction, despite a facility policy requiring provision of needed behavioral health services.
A resident with schizophrenia, mood disorders, cognitive impairment, and a history of agitation and assaultive behavior experienced multiple behavioral emergencies, including physical aggression toward staff, attempts to elope, and self-harm resulting in lacerations requiring sutures. Despite a PASRR identifying significant behavioral health needs and the facility’s policies requiring person-centered assessment, IDT review, and root cause analysis after behavioral crises, the facility did not document an IDT meeting to analyze underlying causes or to develop and revise individualized interventions. Care plan problems related to aggression and self-inflicted injury were marked as resolved shortly after incidents and before the resident’s return from psychiatric hospitalization, and new elopement behaviors and frequent Code Greens were not translated into specific, updated care plan interventions. Staff and other residents reported fear of the resident’s erratic outbursts, staff relied informally on smoking to calm the resident even though it was not listed as a coping skill, and the facility failed to consistently notify the physician of ongoing behavioral emergencies as required by policy.
A resident admitted with bipolar I disorder with psychotic features and schizophrenia, and discharged from the hospital with instructions for psychiatric follow-up and medication management, did not receive behavioral health services after admission. The admission care plan lacked a behavioral focus despite multiple psychotropic medications and a Level II PASRR. Over several weeks, staff documented repeated episodes of calling out and screaming, and an observation showed the resident yelling for assistance with the call light on for an extended period. The admitting nurse did not recall processing a psychiatry referral, the Social Services Director reported no referral or psych consent and that the resident was not on the psychiatric provider’s active list, and leadership stated they expected residents to receive needed behavioral health care but were unaware this resident had not been referred or seen.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Failure to Investigate and Respond to Resident’s Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond to a resident’s verbalization of suicidal ideation as required by the resident’s care plan and facility policy. The resident had diagnoses of Alzheimer’s disease, anxiety, and depression, and a current MDS showed significant cognitive impairment with a BIMS score of 4. The resident’s care plan for depression with a history of suicidal ideation directed staff to immediately notify a supervisor and redirect the resident when suicidal comments were made. On 3/9/2026, a progress note documented that the resident told a volunteer she had nothing to live for and wanted to kill herself, and a 1:1 visit log from that same encounter recorded the same statement. However, there were no additional progress notes or documentation showing that the suicidal ideation was further assessed, that the care plan interventions were implemented, or that the provider was notified. Interviews revealed multiple communication and follow-through failures. The DON stated that any resident verbalizing suicidal ideation should be asked if they had a plan to harm themselves, the care plan should be reviewed and followed, and the resident might be sent for inpatient psychiatric care if appropriate. A QMA who regularly worked on the resident’s unit reported she was not aware of the suicidal statement made on 3/9/2026, although she recalled the resident had made suicidal remarks upon admission months earlier. The Life Enrichment Specialist stated that volunteers complete visit logs and that she entered the 3/9/2026 log into the computer on 3/18/2026, at which time she read the suicidal statement but did not report it as she should have. The volunteer reported that after hearing the suicidal statement, he offered supportive words and then reported it to staff on an adjacent unit when he could not immediately find the unit nurse. The facility’s “Suicide Threats” policy required immediate reporting of any suicide threats to the Nurse Supervisor, continuous supervision of the resident, completion of a Columbia Suicide Severity Rating Scale, reporting findings to the provider, following any provider orders, and documenting the situation, but these steps were not carried out for this resident’s suicidal verbalization.
Failure to Implement Behavioral Health Care Plan and Maintain Safe Environment for Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services to a resident with serious mental illness, a history of trauma, and known coping mechanisms, resulting in multiple self-harm incidents. The resident had diagnoses including schizoaffective disorder, mood disorder, ADHD, PTSD, opioid abuse, anxiety disorder, and insomnia, with a documented history of severe bullying, sibling suicide, homelessness, substance abuse, and the death of a child. The PASRR and care plan identified the need for a low-stimulation environment, consistent routines, psychotherapy, ongoing psychiatric care, and person-centered, trauma-informed interventions. The care plan also directed staff to monitor for anxiety, avoid power struggles, provide opportunities for healthy energy release, and use non-invasive coping mechanisms before behavioral outbursts. Staff were aware that the resident’s coping mechanisms included watching calming television programs (especially Animal Planet), gaming, music, and writing in notebooks. On one occasion, the resident’s guardian reported that the resident had voiced self-harm ideations, after which the resident was placed on one-on-one supervision and staff were instructed to search the room and remove harmful objects. Items with cords, including the television, gaming system, power cords, shoelaces, and hoodies with strings, were removed from the room. Two days later, while on one-on-one observation, the resident repeatedly requested the return of the television to watch Animal Planet, a known coping mechanism, and repeatedly asked to see the Environmental Services Supervisor to help get the television back. The one-on-one staff member assigned that day had never previously provided one-on-one observation and understood their role as only to prevent the resident from hurting self or others. The staff member did not provide additional interventions or access to the television, and the Social Services Designee later stated there was no reason to keep the television and personal items from the resident while on one-on-one observation and was not aware of the resident’s repeated requests or escalating distress. As the resident’s requests for the television went unmet and the Environmental Services Supervisor was unavailable, the resident became increasingly agitated, knocked over linen carts, threw items in the hallway, and then went to the room and broke the inside pane of the double-pane window. The resident sat on the bed surrounded by glass, picked up a shard, and cut the left forearm from elbow to wrist, requiring emergency transport for medical and psychiatric evaluation. After the resident’s return from the hospital, staff failed to ensure the room was free of remaining glass shards. The resident later found glass in the windowsill and under the bed on separate occasions, cutting the same forearm multiple times while alone in the room. Staff documentation and interviews confirmed that shards remained in the windowsill and curtain area and that the room had not been thoroughly cleared of glass before the resident’s return. Although the care plan was updated to include high suicide risk and the need for a written safety plan and specific self-harm interventions, the record showed no evidence that staff collaborated with the resident to develop the written safety plan as directed. These actions and inactions demonstrate the facility’s failure to implement care-planned, person-centered behavioral health interventions, to maintain a safe environment free of known hazards, and to provide necessary services to support the resident’s highest practicable mental and psychosocial well-being. The deficiency is further supported by staff and resident interviews describing the mismatch between the resident’s identified needs and the care actually provided. Staff acknowledged that the resident’s coping mechanisms included watching calming animal shows and gaming, and that removal of personal items, including the television, increased the resident’s agitation. The resident reported feeling that staff had taken away all coping mechanisms, leaving nothing to do while on one-on-one observation, and stated that close proximity and talkative staff increased anxiety. The resident described breaking the window with a metal cup, cutting the left forearm to obtain transfer to the hospital, and later intentionally searching the windowsill and under the bed for glass shards to cut the arm again. The Social Services Designee confirmed that glass shards from the initial incident remained in the room and that staff did not thoroughly clean the room before the resident’s return. Additionally, although the care plan called for development of a written safety plan and teaching alternative coping skills, the record contained no documentation that such a written safety plan was created with the resident, indicating a failure to implement the care-planned intervention for managing self-directed violence risk.
Delay in Providing Requested Behavioral Health Services
Penalty
Summary
The facility failed to provide timely behavioral health services to a resident who requested psychological therapy. The resident, admitted with muscular dystrophy and cognitively intact with a BIMS score of 15, had a PHQ-9 score of 17 indicating moderately severe depression. In mid-January 2026, the resident told the Ombudsman that he wanted talk therapy. The Ombudsman relayed this request to the Social Services Director (SSD), who stated she verbally informed the Director of Nursing (DON) the same day that the resident was asking for psychological therapy. Despite this, no referral for mental health services was initiated at that time. The DON later stated she was not aware of the resident’s request on 1/14/26 and only became aware of it on 2/19/26 after receiving an email from the Ombudsman to the SSD stating that the resident wanted psychological treatment. The referral for treatment was not started until 2/25/26, and the resident was not seen by a psychiatrist or psychologist until 3/2/26, resulting in a 45-day wait from the initial request. During this period, the resident reported feeling like he was going crazy, hearing things loudly, being unsure if the voices were real, being unable to sleep at night, and having no energy during the day. Observation showed the resident sitting quietly in activities and not interacting with others. The DON acknowledged that without timely intervention, the resident could escalate to severe depression with associated decline in ADL function. The facility’s Behavioral Health Services policy stated that residents will receive behavioral health services as needed to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Perform Root Cause Analysis and Person-Centered Behavioral Care Planning After Repeated Behavioral Emergencies
Penalty
Summary
The deficiency involves the facility’s failure to provide thorough, person-centered behavioral health assessment and care planning for a resident with serious mental illness and a history of behavioral issues, including wandering and assaultive behavior. The resident’s PASRR documented schizophrenia, psychosis, major depressive and mood disorders, substantial cognitive impairment, poor judgment and insight, wandering without knowing where he or she was, agitation, assaultive behaviors, and a need for a secured behavioral unit and structured environment. The PASRR also identified needs for psychiatric follow-up, behavioral monitoring, and interventions to change inappropriate behavior. Despite this, the resident’s care plan listed only general behavioral problems such as verbal aggression, agitation, mood swings, anxiety, and aggression, with broad non-pharmacological interventions and triggers, and did not incorporate all PASRR information or clearly defined, individualized coping strategies. Smoking, which staff later used as a primary de-escalation tool, was not listed as a coping skill. On one date, the resident exhibited escalating behavior, yelling and using profane language toward staff, threatening another resident, and ultimately throwing a wet floor sign that struck a staff member in the face, causing injury and requiring EMS and police involvement. A behavioral emergency (Code Green) was called, and the resident was transported to a psychiatric hospital. Facility documentation, including the Registered Nurse Investigation and care plan entries, noted that an IDT meeting was “in progress” and referenced review of the PASRR and physician notification, but there was no documented interdisciplinary team meeting that analyzed the underlying causes of the behavior or revised the care plan with new, individualized interventions. The care plan problems related to physical aggression and staff injury were marked as “resolved” on the same day they were initiated and before the resident returned from the hospital, and the plan of care section that was supposed to list new interventions did not contain specific, updated approaches. After the resident’s return, the facility failed to recognize and address new elopement-related behaviors through assessment and care plan revision. Shortly after being assessed as having no history of elopement, the resident left the secured unit, rapidly wheeled to the front entrance, and then into a family room where he or she broke a glass window with a hand in an attempt to leave the facility, sustaining lacerations that required 20 sutures and emergency room treatment. Staff interviews described the resident yelling about wanting to leave, bursting out of the secured unit when the door opened, and multiple staff being afraid of the resident. There was no documentation of an IDT meeting to determine root causes of this new elopement behavior or to develop person-centered interventions, and the care plan problem for the self-inflicted injury from breaking the window was also marked as resolved before the resident returned from a subsequent psychiatric hospitalization. Following the resident’s second return from psychiatric hospitalization, the resident continued to have frequent behavioral emergencies, including verbal aggression, self-harm behavior involving reopening sutured wounds, and repeated attempts to leave the facility, resulting in five Code Greens over a 10‑day period. Observations showed the resident leaving the secured unit without staff, going to the front entrance, yelling and demanding to leave, and requiring behavioral emergency responses. Staff reported that the only effective redirection was allowing the resident to smoke, yet smoking was not incorporated into the care plan as a coping skill. The facility did not consistently notify the physician of these ongoing behaviors as required by policy, and the care plan revision dated after another front-door incident documented a new problem of unprovoked verbal aggression and attempts to leave but left the interventions section blank. Residents and staff reported being fearful of the resident’s erratic outbursts, and the record showed no documented root cause analysis or comprehensive, person-centered behavioral care planning to address the resident’s changing behavioral health and elopement-related needs. The facility’s own policies on Behavioral Health Services, Behavioral Emergency, and Intensive Monitoring required person-centered assessment and care planning, IDT involvement, root cause analysis, close monitoring for residents with behavioral crises, and physician/psychiatrist notification after behavioral emergencies. Despite these policies, the record for this resident lacked evidence of thorough review of behavioral health emergencies, lacked documented IDT analysis of underlying causes, and failed to update and individualize the care plan with effective interventions in response to repeated behavioral crises, new elopement behavior, and ongoing aggression and distress.
Failure to Provide Behavioral Health Services for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to provide behavioral health care services to a resident with diagnosed serious mental illness and ongoing behavioral symptoms. The resident was discharged from the hospital with diagnoses including bipolar I disorder, current manic with psychotic features, and schizophrenia, and the hospital discharge summary documented a need for follow-up psychiatric appointments and medication management. On admission, the resident’s care plan dated 01/23/26 did not include a focus area for behaviors despite these diagnoses and the presence of multiple psychotropic medications, including olanzapine, lamotrigine, and fluphenazine decanoate. The admission MDS indicated intact cognition, no behaviors coded during the lookback period, and a Level II PASRR, and the resident was coded as receiving antipsychotic medications. Behavioral documentation on the MAR from 01/23/26 through 02/13/26 showed repeated episodes of calling out and screaming/calling out on multiple days, yet the medical record from 01/23/26 through 02/16/26 contained no evidence that psychiatric or other behavioral health services were provided. During observation on 02/16/26, the resident’s call light remained on while he yelled for assistance for over 20 minutes, and a med aide acknowledged that he frequently yelled out but did not know how long he had been yelling on that occasion. The admitting nurse stated she did not recall seeing a psychiatry referral, explained that her process was to place such referrals in the social worker’s box, and did not know why the resident had not been seen by psychiatry despite his behaviors. The Social Services Director confirmed she had not received a referral or completed a psych consent for this resident and that the resident was not on the psychiatric provider’s active list. The Medical Director and DON both stated they expected residents to receive necessary behavioral health care services and were unaware that this resident had not been referred to or seen by psychiatric providers.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
