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:
Failure to identify and monitor target behaviors for a resident with depression. A resident with major depressive disorder, spinal stenosis, and moderately severe depression was on antidepressant and antipsychotic medications, but the care plan, provider order, and TAR did not clearly identify specific behaviors to monitor. Staff documented behavior monitoring on the TAR, yet no target behaviors were identified in the record, and progress notes lacked evidence of any behaviors. During interview, the resident described feeling very depressed and losing interest in prior activities, while RN-A, the DON, and the CP all acknowledged the monitoring order did not clearly define what behaviors staff should be watching for.
A resident with major depressive disorder, depression symptoms, and suicidal thoughts did not receive continued behavioral health services as reflected in the record. Psychiatry notes documented loneliness, grief, poor sleep, low interest, and suicidal thoughts without plan or intent, and therapy was referred, but there were no later psychiatry notes, no scheduled therapy follow-up, and the care plan lacked non-pharmacological interventions. Staff also did not have the psychiatry information in the EMR, and the SSD and ADON were unaware of key mental health findings and documentation gaps.
Failure to provide recommended behavioral health follow-up for two residents. One resident with anxiety, bipolar disorder, and major depressive disorder, and another resident with anxiety and depression, both had care plans and psychiatric consults recommending therapy/LPC follow-up, but there was no documented evidence they received the ordered psychiatric or psychological services. The DON confirmed the missed follow-up services.
Failure to Address Wandering Resident Entering Another Resident’s Room: A resident with dementia and a known wandering pattern repeatedly entered another resident’s room after staff were told the other resident did not want him/her there. No additional behavior interventions were put in place at that time, and the wandering resident later entered the room again, was pushed out by the other resident, and sustained a facial fracture.
A resident with depression, dementia, Parkinson's disease, macular degeneration, and anxiety voiced suicidal statements and expressed loneliness and feeling trapped, but the EHR did not show a referral for behavioral health talk therapy. The DON was unaware of the statements, and the NP stated the resident should have been referred for behavioral health services after reporting self-harm thoughts.
Failure to Individualize and Revise Behavioral Health Interventions for Alcohol-Related Behaviors: Two residents with substance use and mental health histories continued to drink and display alcohol-related behaviors, including slurred speech, odor of alcohol, and repeated intoxication. One resident had dementia, anxiety, and depression; the other had TBI, depression, psychotic disorder, and substance use disorder. Despite existing care plan interventions, staff interviews and records showed ongoing alcohol use, limited monitoring of triggers and target behaviors, and a resident-to-resident altercation on the smoking patio that involved yelling, physical contact, and police response.
Failure to Identify and Monitor Target Behaviors for a Resident With Depression
Penalty
Summary
The facility failed to identify and appropriately monitor target behaviors for one resident who was reviewed for mood and behavior. The resident had an admission MDS that identified intact cognition, moderately severe depression, no exhibited behaviors, and use of antidepressant medications. The resident’s diagnoses included major depressive disorder and spinal stenosis, and the care plan noted potential for adverse drug reactions related to daily psychotropic medication use. The care plan also identified alteration in mood and behavior related to diagnoses, adjustment to placement, and loss of independence, and instructed staff to monitor target behaviors and ADRs as ordered. The resident’s PHQ-9 assessment showed a score of 19, indicating moderately severe depression. Provider orders and the TAR directed staff to monitor target behaviors, but the specific behaviors were left blank, and the record did not identify any target behaviors for monitoring. The TAR was documented as completed on nearly every shift, with interventions documented on seven occasions, yet no target behaviors were identified and the progress notes from the review period lacked evidence of any behaviors occurring. During interview, the resident stated feeling very depressed, not liking reliance on others, and having lost interest in prior activities. RN-A stated staff should document observed behavior and interventions, but also said she was not really sure what she should be monitoring for the resident. The DON stated target behaviors should have been identified so staff knew what to watch for, and the CP stated the order failed to identify the specific medication or generic category and did not provide instruction for actual behavior monitoring.
Failure to Provide and Track Behavioral Health Services for Resident with Depression and Suicidal Thoughts
Penalty
Summary
The facility failed to ensure continued behavioral health services were provided for a resident with major depressive disorder, depression symptoms, and suicidal thoughts. The resident told surveyors she felt like giving up, had lost interest in activities, worried about finances, and had previously received counseling that she believed had helped, but she did not know why those counseling sessions stopped. Her record showed repeated PHQ-9 assessments with depression symptoms, including mild to moderately severe scores, and a psychiatry evaluation documented loneliness, grief, poor appetite and energy, daily anxiety, and suicidal thoughts without a plan or intent. The resident’s psychiatry notes showed that her antidepressant therapy was changed multiple times, a follow-up appointment was planned, and a referral was made for mental health therapy because the psychiatrist felt therapy would be beneficial. However, there were no psychiatry visit notes after the initial and follow-up visits reviewed, and the resident was not scheduled for the therapist referral or a psychiatry follow-up appointment. The care plan focused on antidepressant medication and monitoring for side effects and ongoing depression symptoms, but it did not identify any non-pharmacological interventions for depression. Staff interviews showed gaps in communication and documentation related to the resident’s mental health needs. The SSD stated she thought counseling had been offered, but there was no documentation that it was offered or declined, and she did not document her conversations with the resident. The ADON stated psychiatry notes were not in the EMR or reviewed before surveyor request, and she was unaware of the resident’s additional diagnoses, suicidal thoughts, PHQ-9 results showing moderately severe depression, or the therapy referral. The facility policy required assessment, individualized services, and consistent implementation of care approaches for residents with mental health issues.
Failure to Provide Recommended Behavioral Health Follow-Up
Penalty
Summary
The facility failed to consistently provide necessary behavioral health services to meet the behavioral health needs of two residents. The facility’s Behavioral Health Services policy stated that residents should receive necessary behavioral health services to help them reach and maintain their highest level of mental and psychosocial functioning. Resident 8 was admitted with anxiety disorder, bipolar disorder, and major depressive disorder, and a June 2026 MDS showed the resident was cognitively intact with a BIMS score of 15. The care plan identified risk for mood changes related to major depressive disorder, anxiety, and adjustment disorder, with psychiatric consult and treatment as ordered. A psychiatric consultant recommended therapy services for anxiety and depression with follow-up in 45 to 60 days, and an LPC later documented a follow-up talk therapy session and recommended another follow-up, but there was no documented evidence that the resident received the recommended psychiatric or psychological follow-up services by the end of the survey. Resident 61 was admitted with anxiety disorder and depression, and a quarterly MDS showed moderately impaired cognition with a BIMS score of 9. The care plan identified risk for mood changes related to depression and episodes of anxiety, with psychological consultation and treatment and LPC consultation as needed. A psychiatric consultant recommended therapy services for anxiety, depression, insomnia, and dementia with follow-up in 14 to 21 days, and an LPC documented a follow-up talk therapy session and recommended another follow-up, but there was no documented evidence that the resident received the recommended psychiatric or psychological follow-up services by the end of the survey. During an interview, the DON confirmed that both residents did not receive the recommended follow-up psychiatric and psychological services.
Failure to Address Wandering Resident Entering Another Resident’s Room
Penalty
Summary
The facility failed to timely assess a behavior change and timely implement additional behavior interventions for a resident with a history of wandering. The resident had diagnoses of unspecified dementia, mood disorder, and adjustment disorder with mixed anxiety, and the annual MDS showed moderately impaired cognitive skills with long- and short-term memory problems. The resident’s care plan identified wandering into other residents’ rooms and noted the resident was at risk for elopement, with interventions including checking code alert placement each shift and consulting with the MD and psychologist as needed. On 04/15/2025, another resident with dementia and mood disturbance told the SSD and ADON that the wandering resident had come into his/her room and that he/she did not want the resident in the room. The SSD documented that the resident wanted to be left alone and that staff said they would discuss it with the other resident and tell him/her not to come into the room. The record did not show that interventions were added that day to prevent the wandering resident from entering the other resident’s room. On 04/16/2025, the wandering resident entered the other resident’s room again, and the other resident pushed the wandering resident out of the room, causing a fall and a fracture to the left maxillary sinus wall and lateral border of the left orbit. Interviews with staff showed the wandering resident had been observed going into the other resident’s room multiple times, staff had been notified, and the DON stated the resident was on general supervision with a code alert monitor. The DON also stated the incident could have been prevented by moving the wandering resident, and the facility substantiated abuse.
Failure to Refer Resident for Behavioral Health Services After Self-Harm Statements
Penalty
Summary
The facility failed to ensure a resident with major depressive disorder, Parkinson's disease, macular degeneration, Alzheimer's disease, and anxiety disorder received necessary behavioral health care after he exhibited worsening emotional distress and voiced self-harm statements. The resident's care plan documented fluctuating mood symptoms related to sadness, depression, changes in relationships, and personal loss, and directed staff to refer him to behavioral health as needed. A change-in-condition note documented that the resident was crying in his room and stated that he wanted to die because he had no friends, could not leave the facility, and felt like he was in a prison; the provider was notified. However, the electronic health record did not show a referral to behavioral health services for talk therapy after these statements, and there were no physician orders or communication indicating such a referral. The DON stated she was not aware of the resident's statements, and the NP stated that a behavioral health talk-therapy referral should have been made after the resident's statements, but it did not occur.
Failure to Individualize and Revise Behavioral Health Interventions for Alcohol-Related Behaviors
Penalty
Summary
The facility failed to develop, implement, monitor, and revise individualized behavioral health interventions for two residents with alcohol-related behaviors. One resident had diagnoses including non-Alzheimer's dementia, anxiety, and depression, was independent with his wheelchair and most ADLs, and had care plan focuses addressing substance abuse, antidepressant medication, and community life. His record showed a history of suicidal ideations, sadness, low self-esteem, withdrawal, ineffective coping, loneliness, alcohol use, and occasional cocaine use. Although multiple interventions were listed, including discussion of treatment options, observation for behavior patterns and triggers, room checks for smoking, encouragement of activities, and supervision of peer interactions, the record also showed ongoing alcohol use with repeated notes of slurred speech and strong odor of alcohol, including episodes where medications were held and fall precautions were used. The second resident had traumatic brain injury, malnutrition, depression, and psychotic disorder, and used antipsychotic and antidepressant medication. His care plan addressed substance use disorder, mood, and antipsychotic medication, and noted a history of alcohol dependence, stimulant dependence, and cocaine dependence. Interventions included coping skills education, non-pharmacological interventions, discussion of treatment options, and monitoring of mood and alcohol-related behavior. Despite this, the resident continued to have alcohol-related incidents, including intoxication, slurred speech, altercations, and repeated behavioral concerns. The record also showed that staff were not aware of resident-specific care plan interventions regarding intoxication management, and the facility representatives later stated there were no activity recommendations or care plan changes after the incident. On the smoking patio, the two residents were drinking together and became involved in an altercation that drew police involvement. Witnesses and staff described the first resident as intoxicated, loud, belligerent, and aggressive, with repeated requests for cigarettes, while the second resident was also drinking and was involved in the confrontation. Accounts differed on the exact sequence, but the incident involved yelling, physical contact, and a cane being used. Staff interviews showed that some staff did not intervene, some were unaware of the incident in real time, and the overnight nurse was helping elsewhere when the police arrived. The facility later reviewed the event and noted that the residents had been educated about respecting each other and not sharing cigarettes, but the records reviewed showed no individualized behavioral health plan revisions tied to the ongoing alcohol-related behaviors and the resident-to-resident altercation.
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