Failure to Implement Behavioral Health Interventions
Penalty
Summary
The facility failed to provide appropriate behavioral health interventions for a resident, identified as Resident 44, to maintain the highest practicable mental well-being. The clinical record review revealed that Resident 44 exhibited behavioral symptoms not directed towards others, such as physical symptoms and verbal/vocal symptoms. Despite these behaviors, the facility did not develop a care plan that included an intervention for two staff to provide care due to the resident's known behavior of making false accusations. The plan of care initiated on December 7, 2024, included instructions for staff to remove themselves and reattempt care when the resident was calmer, but these interventions were not implemented during an incident on February 28, 2025. During an interview, Resident 44 expressed dissatisfaction with the approach used by staff during her shower care, describing it as "slam bam." The resident recounted the incident multiple times, indicating distress. Employee 3, a nurse aide, confirmed witnessing the incident and noted that Resident 44 became agitated, falsely accusing staff of hurting her shoulder and damaging her hearing aids, which were not present during the shower. The facility's failure to implement the care plan interventions and develop a comprehensive plan addressing the resident's behavioral health needs led to the deficiency identified by the surveyors.
Plan Of Correction
1. Resident 44's care plan was updated to indicate behavioral health interventions. 2. The Social Services Director reviewed the care plans of any residents with a behavior health concern and updated the care plans as needed to indicate behavioral health interventions. 3. The Facility Administrator educated the social services department on the importance to list any behavior health interventions in the care plan to reflect the residents' needs and interventions. DON will add any interventions to the task section in PCC. 4. The Facility Administrator or designee will complete weekly audits for four weeks then monthly for four months to ensure behavior health interventions are listed on the plan of care. These audits will be brought to the monthly QA meeting for review.