Failure to Monitor and Assess Resident Leads to Tragic Outcome
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with depression and a history of suicidal ideation. The resident exhibited significant changes in behavior, including crying spells, accusations of poisoning, and expressions of fear and anxiety. Despite these clear indicators of a change in condition, the facility staff did not initiate continuous assessment or close monitoring of the resident's behavior, mood, cognition, hallucinations, delusions, or suicidal ideation. The staff also failed to notify the resident's primary care physician of these changes, which was a critical oversight given the resident's mental health history. The resident's care plan, which included monitoring for changes in behavior and mood, was not followed. The Licensed Vocational Nurse (LVN) did not complete a change of condition assessment when the resident exhibited paranoid behavior and verbalized fears of being poisoned. The Social Services Director (SSD) also did not review the resident's history of suicidal ideation or complete necessary assessments, such as the Patient Health Questionnaire (PHQ-9), within the required timeframe. These lapses in care and communication contributed to the resident's deteriorating mental state. Ultimately, the resident was found deceased in the bathroom, having committed suicide. The facility's failure to adhere to its policies and procedures for resident safety, including the lack of a comprehensive assessment and monitoring plan, directly contributed to this tragic outcome. The staff's inaction and failure to communicate significant changes in the resident's condition to the appropriate medical personnel were critical deficiencies that led to the resident's death.
Removal Plan
- The DON provided 1:1 education to LVN 1, CNA 1, Registered Nurse Supervisor, LVNs, and CNAs on the Change of Condition (COC) process, with emphasis on assessment and close monitoring of residents with changes in behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, disruptive vocalizations, and difficulty sleeping.
- Ensured a COC assessment is completed for residents having a change in behavior, including paranoid behavior, verbalization of hurting self, hallucinations, delusions, disruptive vocalizations, yelling, and difficulty sleeping.
- Staff were educated to monitor, document, and report as necessary any change in resident's behavior, mood, cognition, hallucinations, delusions, and suicidal thoughts, and to notify the physician of the COC.
- Provided education on non-pharmacological interventions for residents with depression, including removing stressors, offering food and beverages, increasing therapeutic activities, psychosocial support, encouraging family involvement, and other interventions to ensure a safe environment.
- Educated staff on informing the physician and responsible party when a resident has a COC in behavior, mood, delusions, hallucinations, and suicidal thoughts, and on recognizing residents who are depressed and have a history of suicidal ideation.
- Provided education on behavior management and suicide prevention.
- The Administrator provided 1:1 in-service education to the Social Services Director (SSD) regarding completion of assessments, including PHQ-9, following the Resident Assessment Instrument (RAI) Manual guidelines.
- The DON/designee conducted an audit of current residents with diagnoses of serious mental illness to determine residents who have had a change in behavior, mood, cognition, hallucinations, delusions, or current/history of suicidal ideations or suicide attempt, ensuring assessment, close monitoring, COC completion, care plan initiation, physician notification, and SSD assessments are completed.
- SSD conducted an audit of current residents with diagnoses of serious mental illness, identified residents with changes in mood, ensured assessment by licensed nurse, COC completion, physician notification, and completed PHQ-9 assessments for all identified residents with depression.
- The DON/Designees conducted interviews of current interviewable residents to identify any potential changes in behavior or mood.
- The DON/Designee provided in-service education to staff on Behavior Management/Suicide Management.
- The DON/Designee initiated in-service education to department heads and staff regarding policies and procedures for Behavior/Psychoactive Medication Management, Change of Condition Notification, Behavior - Threats to Harm Self, and Comprehensive Care Planning.
- The Regional Social Service Consultant provided in-service education to the Social Service Designee on the Policy and Procedure titled Social Service Assessment and Social Service Program, emphasizing the importance of completing required Social Service Assessments, including the PHQ-9 per regulatory guidelines.
- The Administrator and DON will present the results of the Admission/Readmission, and Change in Condition Audits, and Resident Interviews to the Quality Assurance and Performance Improvement Committee for review and recommendations until substantial compliance is achieved.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of making allegations of rough care and a care plan requiring all care to be provided by two caregivers was assisted by a single CNA, contrary to the documented "cares in pairs" intervention. The care plan identified manipulative behavior and alleged mistreatment, and specified that two caregivers should be present to address the resident’s needs and observe the entire care session. On one occasion, the CNA entered the room alone and began providing care, after which the resident reported to an LPN that the CNA had been rough, leading to a deficiency citation for failure to follow the resident’s care plan under F684.
The facility failed to monitor and develop individualized interventions for sexually focused behaviors in multiple cognitively impaired residents. Several residents with dementia had documented histories of inappropriate touching, hypersexuality, or intimate relationships with other residents, yet behavior monitoring orders and tools focused only on depression, anxiety, or general boundary issues. One resident was observed performing oral sex on another resident, and another was found receiving oral sex, while another made explicit sexual comments and requests to CNAs. Care plans for companionship emphasized hand holding and social engagement but did not include specific monitoring or tailored interventions for sexual behaviors, and the facility had no formal assessment for sexual behaviors despite policy requiring daily monitoring of target behaviors and social services involvement in behavior care planning.
A resident with multiple serious mental health diagnoses, including bipolar disorder, PTSD, anxiety, panic disorder, delusional disorder, and dementia, was admitted after an extended psychiatric hospitalization with orders and consent in place for psychiatric services, counseling, and medication management. Despite a PASSAR requirement for individual therapy and care plans calling for psychiatric referrals, counseling, and supportive group or one-on-one therapy, the clinical record showed no documented mental health services over extended periods, and the resident reported not receiving therapy and wishing to attend it. Staff, including a unit manager and the DON, confirmed the resident was not currently being seen by a psychiatric provider or receiving mental health services, and the facility lacked a policy on mental health services.
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.
A resident with bipolar disorder, morbid obesity, and diabetes repeatedly refused a prescribed trazodone 50 mg dose for insomnia over multiple days, later reporting passive suicidal ideations and emotional distress. Although the MAR documented numerous refusals and a behavioral health note described an ED visit for passive suicidal ideation and concerns about antidepressant inconsistencies, there was no documentation that the physician was notified of the refusals until the medication was discontinued. The SSD and Social Service Assistant were unaware of the trazodone prescription and the refusals, and the refusals were not discussed in clinical meetings as was customary, contrary to the facility’s documentation policy requiring recording of services and changes in condition.
A facility failed to provide necessary behavioral health services and effective supervision to prevent inappropriate sexual contact between residents. In one case, a cognitively impaired resident with borderline intellectual functioning inappropriately touched another resident’s leg in a lobby area, and the affected resident later reported minimal follow-up and no documented assessment of the incident in her health status note. In another case, a resident with vascular dementia reported that another cognitively intact resident touched her breast in a hallway, despite prior documentation of that resident touching another resident inappropriately. In both incidents, residents were in common areas without effective supervision, and the facility did not proactively implement sufficient behavioral interventions or consistent behavioral health follow-up for the affected residents.
Failure to Follow Care Plan Requiring Two Caregivers During Resident Care
Penalty
Summary
Non-compliance at F684 occurred when a resident who was care planned to receive all care from two caregivers at all times was assisted by a single CNA. The resident had a documented history of making allegations of staff being rough and was identified in the care plan as requiring "cares in pairs" with two caregivers present to address her needs and observe the entire care session. Despite this, the CNA entered the resident’s room alone and began providing care without a second staff member present, contrary to the resident’s care plan and the facility’s expectations. The resident’s care plan, initiated on 10/28/22, identified manipulative behavior and alleged mistreatment as focus areas, noting that the resident might voice allegations of mistreatment or exploitation by caregivers, related to feelings of loss of independence, and might use abusive language. Interventions included assuring the resident she was safe and secure, providing two caregivers to address her needs and observe the entire session, having supervisory personnel observe care delivery as much as possible, and offering staff of certain racial backgrounds when able, based on the resident’s stated preferences and history of accusations. On the date of the incident, the resident reported to an LPN that the CNA had been rough with her during care that was provided without a second caregiver present. Staff interviews confirmed that the resident was known to make accusations, tell inconsistent stories, and sometimes scream even before being touched, and that she was to always receive care with two staff present because of these behaviors and prior allegations. On the day of the incident, staff on duty reported hearing the resident screaming after the CNA entered the room and began helping her, then left to get a second person to assist. The CNA acknowledged going into the room alone and assisting the resident with care, thereby not following the resident’s care plan requirement for two caregivers to be present during care, which led to the cited deficiency under F684.
Failure to Monitor and Individualize Care for Sexually Focused Behaviors in Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to monitor and develop individualized interventions for cognitively impaired residents who exhibited sexually focused or intimate behaviors. Five residents with dementia or significant cognitive impairment had either documented sexually focused behaviors, hypersexuality, or intimate relationships with other residents, yet their behavior monitoring and care plans did not include specific assessments, monitoring, or individualized interventions for sexual or intimate behaviors. Instead, behavior monitoring orders and tools focused on depression, anxiety, delusions, or general boundary issues, and there was no structured assessment for sexual behaviors in use at the facility. One resident with moderate cognitive impairment and dementia (Resident B) had behavior monitoring ordered for depression-related symptoms and a care plan for impaired cognition and poor safety awareness, but no monitoring or individualized interventions for intimate or sexually focused behaviors. Social services documented that she sought companionship with a male resident, ate meals with him, and sat in the lounge with him, with her representatives agreeing to the relationship and the facility stating it would continue to monitor. Subsequently, staff observed her performing oral sex on a male resident in her room, after which staff intervened and removed the male resident. Prior to this event, her record lacked behavior monitoring or care plan interventions specifically addressing intimate or sexual behaviors. Another resident with severe cognitive impairment and delusional disorder (Resident C) had a history of inappropriate personal boundaries, including touching others’ arms and legs, and was treated with medroxyprogesterone for hypersexuality with multiple dose adjustments and a failed gradual dose reduction. His resolved care plan for inappropriate boundaries included general boundary-setting strategies, and a current care plan acknowledged his companionship with female peers and allowed affectionate acts such as hand holding and putting his arm around them. However, his clinical record did not include monitoring tools or individualized interventions specifically targeting intimate or sexual behaviors. Nursing and social service notes documented increased friendliness and physical contact with female residents, agitation when redirected, and an incident where he was found in a female resident’s room receiving oral sex, but behavior monitoring tools reflected only irritability, anxiety, and searching for family, not sexual behaviors. Residents D, E, and F, all with dementia and varying levels of cognitive impairment, had prior care plans for inappropriate personal boundaries that were later resolved and replaced with care plans describing mutual companionship with male peers, including hand holding and arm-around contact. These care plans emphasized acknowledging the need for connection, assessing understanding and ability to refuse, encouraging appropriate touch, offering privacy, and psychosocial visits, but did not include individualized monitoring or interventions specifically for sexually focused behaviors. Resident E exhibited verbally explicit sexual comments toward CNAs, including references to genital areas and suggesting sexual acts involving staff and another male resident, yet her behavior monitoring orders and tools addressed only depression and did not capture or target sexualized behaviors. Resident F’s record showed a long-standing close relationship with a male resident, family awareness of his frequent touching of her hands and legs, and discussion of possible environmental interventions, but her behavior monitoring focused on anxiety and searching for her daughter, with no documented monitoring or individualized interventions for intimate or sexual behaviors. The Social Service Director confirmed that the facility did not have a sexual behavior assessment, that behavior tools used by CNAs did not include sexual behaviors for these residents, and that decisions about resolving or framing care plans were influenced by discussions with the Ombudsman about residents’ rights rather than by structured behavioral health assessment and monitoring. Overall, the facility’s behavior management process, as described in policy and interviews, required nursing to monitor target behaviors daily and social services to maintain a list of residents with behaviors and assist with behavior care plans. However, for these five residents with documented sexually focused behaviors, hypersexuality, or intimate relationships, the facility did not implement behavior monitoring specific to sexual behaviors, did not develop individualized behavioral health interventions addressing those behaviors, and did not use a formal assessment tool for sexual behaviors. Behavior sheets and monitoring focused on other symptoms such as depression, anxiety, irritability, and confusion, leaving sexually focused behaviors unmonitored and without individualized, documented interventions in the clinical record.
Failure to Provide Required Mental Health Services to a Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary mental health services to a resident with multiple serious mental health diagnoses. The resident, who had bipolar disorder, conversion disorder, anxiety disorder, PTSD, panic disorder, delusional disorder, and dementia, was admitted after an extended inpatient psychiatric hospital stay. Initial physician orders dated 9/5/25 authorized psychiatric services, counseling, and medication management, and consent for behavioral health services was obtained from the resident’s next of kin. A care plan initiated on 9/8/25 identified anxiety with an intervention of psychiatric services per order. However, a physician’s order allowing evaluation and treatment for psychology and psychiatry services was discontinued on 10/12/25, and a level of care document dated 11/17/25 showed zero days of psychological therapy. A PASSAR dated 11/19/25 required the facility to provide mental health services such as individual therapy. The clinical record contained no documentation of mental health services from 9/5/25 to 1/11/26. On 1/12/26, a psychiatric telehealth visit determined the resident was eligible for behavioral health integration and psychiatric collaborative care management, and the resident consented to enroll. Care plans dated 2/6/26 documented PTSD, use of antipsychotic medications, and a history of severe, persistent mental illness, with interventions to refer the resident to psychiatric services, appropriate individual counseling or other mental health programs, and to involve the resident in supportive group or one-on-one counseling. A psychotropic drug evaluation dated 3/5/26 indicated the resident was receiving psychiatric services, yet the clinical record again lacked documentation of mental health services from 1/13/26 to 3/26/26. A quarterly social service interview on 3/10/26 recorded moderate depression symptoms with a PHQ-9 score of 13. During observations and interviews, the resident reported not receiving mental health services, stated she would like to attend therapy, and said staff had not asked if she wanted therapy. Staff interviews confirmed the resident was not currently being seen by a psychiatric provider or receiving mental health services, and the DON stated the facility did not have a policy regarding mental health services.
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 Address Repeated Refusal of Behavioral Health Medication
Penalty
Summary
The facility failed to ensure a resident with bipolar disorder received necessary behavioral health services when she repeatedly refused a prescribed medication for insomnia without appropriate follow-up. The resident, who was not cognitively impaired and had diagnoses including bipolar disorder, morbid obesity, and diabetes, reported that she believed she had refused an insomnia medication and had been sent to the hospital because she did not care if she died. Physician orders showed trazodone 50 mg at bedtime was started and later discontinued, and the MAR documented multiple refusals of this medication across numerous dates. A behavioral health note recorded that the resident presented to the emergency department with passive suicidal ideations, several life stressors, increased emotionality, and reported inconsistencies with her antidepressant medication. Despite these refusals and behavioral health concerns, the clinical record lacked documentation that the physician was notified of the ongoing refusals until the date trazodone was discontinued. A late-entry progress note indicated the resident’s refusal of trazodone had been discussed in a care plan meeting, but the Social Service Director stated he was not aware of the details of the refusals, and the Social Service Assistant reported she was unaware both of the trazodone prescription and the resident’s refusals. The Social Service Assistant indicated that medication refusals are normally discussed in clinical meetings, but this resident’s refusals had not been discussed to her knowledge. The facility’s charting and documentation policy required that all services performed and changes in condition be recorded to ensure consistency between family, physicians, and social services, but this was not followed in this case.
Failure to Provide Necessary Behavioral Health Services and Supervision for Inappropriate Sexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received necessary behavioral health care and services, specifically by not proactively assessing and implementing effective behavioral interventions to address inappropriate sexual behaviors between residents. Facility policy on Resident Rights states that each resident has the right to be free from mental and physical abuse and to have a safe, secure, and homelike environment, and that the facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. The facility’s Behavioral Health Services policy further requires that all residents receive necessary behavioral health services to help them reach and maintain their highest level of mental and psychosocial functioning. One incident involved a resident with borderline intellectual functioning and severe cognitive impairment, who approached another resident with a cognitive communication deficit while both were seated in the front lobby and touched her leg without consent. The cognitively impaired resident had a BIMS score of 07, indicating severe cognitive impairment. The resident who was touched reported the incident to staff and stated she told him to quit and he left her alone. She later reported that she only spoke once with a nurse about what happened, that there was no further follow-up discussion or additional inquiries from other staff, and that she did not receive any updates regarding the outcome of the investigation. Her health status note for the date of the incident contained no documentation of the inappropriate touching. She also reported seeing the other resident’s name still listed on the room across from hers and stated she planned to avoid him and common areas if he returned. Record review showed that another female resident later reported that the same cognitively impaired resident inappropriately touched her twice on her leg and between her thighs. A separate incident involved a resident with vascular dementia and moderate cognitive impairment, who reported that another resident with a cognitive communication deficit and a BIMS score indicating intact cognition touched her breast without consent in the hallway in front of the nurse’s station. The resident who was touched immediately notified a CNA and clearly described that the other resident had touched her breast. Facility records showed that this same resident with intact cognition had previously been noted at the nurses’ desk touching another resident inappropriately and, when redirected, simply looked at the nurse and continued rolling in his wheelchair. In both incidents, record review revealed that the residents were in common areas without effective supervision at the time of the events. Although staff responded after the incidents occurred, the facility did not implement sufficient proactive interventions or supervision to prevent inappropriate resident-to-resident contact before these incidents took place, and affected residents did not receive consistent, documented behavioral health follow-up and support as required by facility policy.
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