Failure to Implement Effective Behavioral Health Interventions
Summary
The facility failed to develop and implement comprehensive, individualized, and effective interventions to meet the behavioral health care needs of a resident with significant psychiatric history. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, dementia, anxiety, antisocial personality disorder, hallucinations, body dysmorphic disorder, and a history of suicide attempts, was found unresponsive in a communal shower room due to a self-inflicted injury. This incident occurred after an LPN provided the resident with a pair of scissors to cut his hair, without reviewing the resident's care plan or providing supervision. The resident's care plan included supervision while shaving and noted a history of self-harm and suicidal ideations. Despite this, the LPN did not check the resident's care plan or Kardex before giving the scissors, which were described as safety scissors with a rounded blunted end. The resident was left unsupervised with the scissors, leading to a self-inflicted injury that resulted in significant blood loss and ultimately, the resident's death. Interviews with staff revealed that there was no indication or concern that the resident was suicidal at the time, and no behaviors or statements suggested self-harm intentions. However, the facility lacked a policy addressing suicidal behavior, residents at risk for self-harm, or sharp object safety, which contributed to the incident. The root cause analysis concluded that the incident was due to the LPN providing the resident with a sharp object, which should not have occurred.
Removal Plan
- Resident #93 was noted with acute blood loss, Emergency Medical Services (EMS) was notified, and Resident #93 was transported to a local emergency room (ER) by local EMS providers.
- LPN #500 was immediately provided 1:1 verbal education by the DON on not providing sharp objects to residents.
- LPN #500 was suspended by the Administrator following the incident, pending a thorough investigation. LPN #500 was permitted to return to work.
- The Director of Nursing (DON), ADON #270, Unit Manager #267, Housekeeping Supervisor #283, Human Resource Manager #262, Licensed Social Worker (LSW) #246, Central Supply #317 and Admissions Director #216 completed a whole house sweep for sharp objects with no sharp objects noted.
- All residents were assessed, and medical records were reviewed (including psychiatric/provider notes) to identify those residents who had self-harm and/or suicidal ideation history. In addition, those who could be, were interviewed, related to suicidal ideation/self-harm. Eleven residents (#100, #15, #16, #28, #33, #38, #40, #101, #57, #61, and #102) were identified as at risk for self-harming behaviors. Care plans and associated Kardex's were reviewed by Regional Clinical Support Nurse #244.
- All staff were interviewed regarding any knowledge of residents exhibiting any signs, symptoms, or behaviors which could be indicative of suicidal ideations. This was completed by the Administrator.
- Regional Clinical Support Nurse #244 educated all facility interdisciplinary team members (IDT) on updating care plans for resident(s) who have suicide ideations/self-harm and pulling them to the Kardex.
- All staff were educated by the DON/Designee on reviewing residents' Kardex, ensuring residents were free and safe from self-harm, and assisting and providing supervision to residents as deemed necessary.
- The Administrator completed a quality assessment and performance improvement (QAPI) and a root cause analysis with the Medical Director, DON, ADON #270, Regional Clinical Support Nurse #244, Medical Records #317, Human Resources Manager #262 and LSW# 246. The facility root cause analysis identified the nurse (LPN #500) gave Resident #93 a sharp object and should not have. The facility corrective action plan involved mitigating the risk and availability of sharp objects and identifying those residents at risk for self-harm or suicidal ideations.
- The DON/Designee began random, ongoing resident audits on care plans for residents with a history of suicidal ideations and/or self-harm. The ongoing audits were completed four times weekly for a total of six weeks.
- The DON/Designee began random, ongoing audits of staff competencies regarding staff utilization of the resident Kardex's. The audit reviewed five random staff members four times weekly for a total of four weeks.
- The Administrator held a QAPI meeting with the DON, ADON, Medical Director, Activities Director #201, Medical Records Coordinator #317, Human Resource Manager #262, Regional Clinical Support Nurse #244 and LSW# 246 to discuss the findings of the facility audits.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with bipolar disorder, schizoaffective disorder, major depressive disorder, epilepsy, and other comorbidities experienced a gradual dose reduction of Abilify without timely psychiatric reassessment and with inconsistent behavior documentation. In the weeks before the incident, staff and psychology notes described depression, low energy, poor concentration, anhedonia, and later increased aggression, arguing, medication refusal, and throwing objects, but these behaviors were not consistently charted, and no medication changes were implemented. On an overnight shift, a CNA observed the resident talking to himself, shouting profanities, and becoming highly agitated and unapproachable, while an LPN documented verbal aggression, threatening gestures, and lack of sleep, but hospice was not notified as directed and no effective interventions were implemented. The next morning, the resident was found outside on a snowy hillside about 100 feet from his window, lightly clothed, combative, stating he wanted to die, and showing signs of hypothermia and injury; EMS and hospital records documented altered mental status, psychosis, delusions, hypothermia, frostbite, and placement on an Emergency Application for a suspected suicide attempt. The facility lacked a policy for behavioral or psychological needs and did not follow its change-in-condition policy requiring physician consultation for significant mental or psychosocial changes.
A resident with severe cognitive impairment, dementia, and a history of trauma involving males was provided incontinence care by two male staff members, contrary to her care plan specifying a preference for female caregivers. The resident verbally refused care and expressed distress during the incident, but the male staff continued until a female RN intervened. Subsequent assessments noted bruising and discoloration, and the facility's policy for person-centered care was not followed.
A resident with a history of schizophrenia, paranoia, and hoarding behaviors repeatedly acquired and mixed hazardous chemicals despite requiring 24-hour supervision. Staff were aware of the ongoing behaviors but did not implement timely, individualized psychosocial interventions or update the care plan in response to escalating risks. The situation resulted in the resident sustaining chemical burns to both feet, requiring hospital and burn center treatment.
Following traumatic incidents such as alleged abuse, unexplained bruising, and theft, three residents with intact cognition and various medical conditions did not receive counseling or psychosocial support. Social service notes lacked documentation of follow-up, and interviews confirmed that no staff checked on the residents' mental health needs after the events.
A resident with severe depression, PTSD, and anxiety did not receive appropriate mental health services despite expressing a desire to see her psychiatrist and psychologist. The facility's plan of care included arranging services from a Licensed Mental Health Provider, but this was not implemented, leading to a deficiency in care.
The facility failed to provide necessary psychiatric referrals and interventions for two residents with mental health and behavioral issues. One resident, with a history of dementia and PTSD, did not receive a psychiatric referral despite physician recommendations. Another resident, with severe cognitive impairment, exhibited aggressive behaviors without a care plan in place to manage these actions. Both cases highlight a lack of timely psychiatric evaluation and intervention.
Failure to Assess and Respond to Resident’s Acute Mental Health Decline Leading to Harm
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, document, and address a resident’s mental health decline and behavioral changes, despite the resident’s significant psychiatric history and hospice status. The resident had diagnoses including bipolar disorder, schizoaffective disorder, major depressive disorder, epilepsy, COPD, and CKD, and was receiving hospice services. Antipsychotic medication (Abilify) had been gradually reduced from 10 mg to 5 mg on 11/11/25 and then to 2.5 mg on 12/11/25 as a gradual dose reduction. Psychology notes from 12/10/25 and 12/24/25 documented depression, low energy, poor concentration, and lack of motivation, but no psychosis, hallucinations, or suicidal ideation at those times. Behavior documentation from 12/07/25 through 01/02/26 showed no recorded behaviors, despite later staff reports of aggression and mood changes. On 12/22/25, nursing documentation noted low energy, inability to sleep, quiet and flat affect, and a behavior note described anhedonia and sadness. A PHQ-9 interview on 12/23/25 recorded no mood symptoms and indicated no need for a staff mood interview. On 12/24/25, psychology documented depressed affect, low energy, poor concentration, lack of interest, and sadness, but still no psychosis or suicidal ideation. On 12/30/25, a nursing progress note stated hospice was advised of increased aggression and that a PNP would adjust medications; however, there was no corresponding documentation of the resident’s aggression in the behavior charting, no record that the PNP actually saw the resident that day, and no evidence of any medication changes. A later interview with an RN clarified that the resident had been arguing with a roommate, refusing medications, and throwing things in his room, but these behaviors were not captured in the behavior documentation. During the night shift of 01/01/26–01/02/26, a CNA reported that the resident was “not right” and “actually scary,” lying in bed talking quietly to himself, shouting profanities when staff walked by, and becoming more agitated when approached, acting as if he would get out of bed. The CNA, who had cared for the resident for two to three years, stated this behavior was very out of character and reported her concerns to the LPN. The LPN attempted to give evening medications around 7:30 P.M., which the resident refused, and stated the door was kept open to observe him. The LPN later sent a text to the physician at 6:07 A.M. about the behaviors and lack of sleep but did not contact hospice as instructed by the DON and did not receive a response before leaving at 6:36 A.M. Behavior charting for 01/02/26 at 5:59 A.M. documented that the resident was verbally aggressive, yelling profanities, making threatening gestures, unapproachable, highly agitated, awake all night, and talking loudly with aggressive, profane language to himself; it also stated that the physician and on-call provider were notified, but there was no evidence of interventions implemented throughout the night. On the morning of 01/02/26, the DON reported receiving a call around 6:00 A.M. from the hall nurse about the resident talking to himself and to people who were not there and instructed the nurse to call hospice. The DON arrived at approximately 7:00 A.M., was told the resident was sleeping, and did not check on him. Hospice later confirmed the facility did not contact them about the change in mental status and that hospice only became aware when their nurse arrived for a routine visit and saw EMS assisting the resident. Around 7:50 A.M., a transportation driver arriving at the facility saw something in the snow and discovered the resident outside approximately 100 feet from his window, on his knees in the snow, agitated, stating he wanted to die, with abrasions, bright red skin, and wearing only light clothing. Facility staff and EMS reports indicated the resident was combative, aggressive, and psychotic, with altered mental status, injuries, and signs of hypothermia in temperatures around 21°F. EMS and hospital records documented that the resident was found kneeling in the snow with a cold wet blanket, with drag marks suggesting he had rolled down a hill from a first-floor window approximately 77 inches above the ground. The resident was pale with purple extremities, abrasions, and nonblanchable skin over heels and knees, and required soft restraints and sedative medication due to combative behavior. At the hospital, he was described as cold to the touch, with a core temperature of 95.6°F, delusions (including stating he was pregnant), and paranoia. He was admitted with hypothermia due to exposure, stage one frostbite to the heels, and delusions, and was placed on an Emergency Application for suspected suicide attempt after reportedly jumping from his window and remaining in the snow. Interviews with the PNP and hospice staff revealed discrepancies in Abilify dosing between hospice and facility records, lack of timely psychiatric reassessment after the GDR, and inconsistent or missing documentation of behavioral concerns. The facility’s Administrator and Vice President of Clinical Operations confirmed there was no facility policy related to meeting residents’ behavioral or psychological needs, and the facility’s change-in-condition policy required physician consultation for significant changes in mental or psychosocial status, which was not consistently followed in this case.
Failure to Provide Trauma-Informed, Person-Centered Care for Resident with History of Trauma
Penalty
Summary
A deficiency occurred when a resident with a documented history of trauma and a preference for female caregivers was provided incontinence care by two male staff members, despite clear care plan interventions specifying the resident's wishes. The resident, who had severe cognitive impairment, dementia, depression, anxiety, and a history of trauma involving males, was observed on video objecting to the care, verbally refusing, and expressing distress during the incident. The care plan, which was last updated to reflect the resident's trauma history and preference for female caregivers during showers and checks/changes, was not followed during this event. Medical records and interviews confirmed that the resident's family had communicated the preference for female caregivers upon admission, and this was initially accommodated. However, after the resident was moved between floors, male caregivers resumed providing care without documented objection from the family until the incident in question. On the day of the incident, the resident was resistive to care, repeatedly said "no," and expressed that her hand was being hurt while the two male caregivers continued with incontinence care. A female RN eventually completed the care after the male staff left the room. Subsequent assessments and review of photos revealed bruising and discoloration on the resident's hands and arms, though the facility attributed some of these marks to previous lab draws and a fall. The facility's own policy required person-centered care that maximizes dignity, autonomy, and choice, but the actions taken did not align with these standards. The DON confirmed that the care plan should have been followed and that care should have been paused and resumed later if the resident refused.
Failure to Address Psychosocial Needs and Prevent Harm from Hazardous Behaviors
Penalty
Summary
The facility failed to timely address the psychosocial needs and implement individualized interventions for a resident with a history of mental disorder, paranoia, hoarding behaviors, and a pattern of acquiring hazardous chemicals. The resident, who had diagnoses including schizophrenia with disorganized thoughts, anxiety, and paranoia, was noted to have intact cognition but poor decision-making skills. Despite being identified as requiring 24-hour supervision and having a care plan that included interventions for behaviors potentially causing harm to self or others, the resident continued to obtain and hoard facility chemicals over several months. Staff interviews and record reviews revealed that the resident's behaviors, including acquiring and mixing cleaning chemicals, were known to the staff and had been ongoing. On one occasion, staff found a spray bottle in the resident's room containing mixed chemicals, and on a prior day, other cleaning chemicals were also found and removed. The psychiatric nurse practitioner was unaware of the recent escalation in behaviors and hospitalizations, despite noting an increase in behaviors earlier in the year. The administrator confirmed that while the resident was educated about not having chemicals, there was no evidence that the interdisciplinary team addressed the increase in behaviors or implemented a psychosocial plan of care. The deficiency culminated when the resident was found with wet, blistered, and inflamed feet, which upon assessment were determined to be partial thickness burns. The resident was sent to the hospital and subsequently transferred to a burn center for treatment. The facility's policy required person-centered behavioral health care and regular review of care plans, especially when interventions were not effective or when there was a change in condition, but there was no documentation that these requirements were met in this case.
Failure to Provide Psychosocial Support After Traumatic Incidents
Penalty
Summary
The facility failed to provide necessary social services to support the mental health and psychosocial well-being of residents following traumatic incidents. Three residents with varying diagnoses, including depressive disorder, metabolic encephalopathy, and anxiety disorders, experienced incidents such as alleged abuse, unexplained bruising, and theft of personal property. Despite these events, there was no documentation of counseling or follow-up psychosocial services in the social service notes for any of the affected residents during the periods following the incidents. Interviews with the residents confirmed that none had been visited by staff or offered counseling services after their respective incidents, and each expressed ongoing distress or feelings of violation. The Social Service Designee acknowledged that residents should be assessed and offered psychosocial support after such occurrences, but verified that no such visits or assessments had taken place. Facility policy required notification of the social service department after incidents to ensure psychosocial needs were addressed, but this procedure was not followed for the residents involved.
Failure to Provide Mental Health Services for Resident with Severe Depression
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with depression, bipolar disorder, PTSD, and anxiety disorder. The resident, who was admitted following a craniotomy for meningioma, had physician's orders for antidepressant and antianxiety medications. Despite a Minimum Data Set assessment indicating severe depression, the physician progress notes did not address the resident's depression. The resident expressed a desire to see her psychiatrist and psychologist, but there was no evidence of follow-up to schedule these appointments. Interviews with facility staff confirmed the resident's severe depression and her request for mental health services. The resident, who has a history of trauma and prefers not to have male caregivers, had not seen a mental health professional since admission. The plan of care included an intervention to arrange services from a Licensed Mental Health Provider, but this was not implemented, leading to the deficiency in providing necessary mental health support for the resident.
Failure to Provide Psychiatric Referrals and Behavioral Interventions
Penalty
Summary
The facility failed to ensure that a resident with a history of mental health issues received appropriate psychiatric referrals and interventions. Resident #85, who was admitted with diagnoses including dementia, PTSD, insomnia, generalized anxiety, and wandering, was prescribed medications such as clonazepam and Zyprexa for anxiety and agitation. Despite physician notes indicating the need for psychiatric follow-up, there was no evidence in the medical record that such a referral was made until the issue was identified during a survey. This oversight left the resident without the necessary psychiatric evaluation and support. Additionally, the facility did not implement interventions to address aggressive behaviors in Resident #71, who was admitted with diagnoses including atrial fibrillation, dementia, and anxiety disorder. The resident exhibited severe cognitive impairment and aggressive behaviors, including an incident where he physically assaulted a CNA. Despite these behaviors, there was no care plan in place to manage the aggression, and the resident had not been seen by psychiatric services to address the increase in behaviors. The lack of timely psychiatric evaluation and intervention contributed to ongoing aggressive incidents, affecting both staff and potentially other residents.
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