Failure to Document Behavioral Assessments for Psychotropic Medication Use
Summary
The facility failed to document behaviors related to psychotropic medication use for three residents with severe cognitive impairment, as required by physician orders. These residents, diagnosed with conditions such as Alzheimer's Dementia, anxiety, and depression, were prescribed various psychotropic medications including antidepressants, antipsychotics, and antianxiety drugs. The Behavioral Assessment Record (BAR) for these residents showed missing documentation on several days across December 2024, January 2025, and February 2025. The electronic health records also lacked progress notes addressing whether behaviors were observed on the days with missing BAR documentation. Interviews with facility staff revealed that the task of completing the BAR was flagged as a reminder during medication rounds. However, on the days when documentation was missing, Certified Medication Aides (CMAs) were responsible for passing medications and did not have access to the BAR or awareness of the task to alert nursing staff. The Director of Nursing acknowledged the incomplete documentation and noted that the missing entries occurred on the same days for all three residents. The facility's policy on Adverse Effects Monitoring Process required professional team members to record adverse effects as indicated, but this was not adhered to in the cases reviewed.
Penalty
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A resident with paraplegia and a history of trauma was involved in an incident where an LPN physically restrained him by blocking his wheelchair, leading to the resident punching the LPN. The resident had grabbed his medication and attempted to leave, contrary to physician orders. This action violated the facility's Resident Rights policy, which ensures residents are free from restraints. The incident was witnessed by staff, and authorities were notified.
The facility failed to ensure sufficient staffing to meet the behavioral health needs of residents, affecting two residents and potentially impacting all 31 residents on a nursing unit. The inadequate staffing led to delays in care and supervision, resulting in falls and hospitalizations for residents with complex behavioral health needs.
Failure to Ensure Resident Rights and Appropriate Behavioral Health Management
Penalty
Summary
The facility failed to ensure appropriate nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of Resident #115, particularly in relation to mobility and behavioral health needs. Resident #115, who had diagnoses including paraplegia and a chronic ulcer, was cognitively intact and required varying levels of assistance for daily activities. The care plan highlighted the resident's risk for impaired psychosocial well-being due to a history of trauma, emphasizing the need for respectful and compassionate communication. However, an incident occurred where the resident grabbed his crushed pain medication from the medication cart and attempted to leave, leading to a confrontation with LPN #402. During the incident, LPN #402 blocked the resident's path and physically restrained him by placing her foot in the wheel of his wheelchair, as the resident was required to take his medication in front of the nurse. This action led to the resident punching the LPN in the hands. The facility's Resident Rights policy, which states that residents have the right to be free from restraints, was not adhered to in this situation. The incident was witnessed by other staff members, and the police, DON, and Administrator were notified. This deficiency highlights a failure in ensuring the resident's rights and appropriate handling of behavioral health needs.
Insufficient Staffing for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the behavioral health needs of the residents, specifically affecting two residents and potentially impacting all 31 residents on the Rosepointe B nursing unit. Resident #101, who had vascular dementia, hemiplegia, hemiparesis, and schizophrenia, exhibited socially inappropriate behaviors and required substantial assistance for daily activities. On multiple occasions, Resident #101 was found on the floor or attempting to remove his incontinence brief and clothing, indicating a need for constant supervision. The staffing on the unit was insufficient, with only two STNAs assigned to care for 31 residents, leading to delays in care and supervision for Resident #101, who eventually fell and was sent to the hospital for evaluation. The staff, including the RN and STNAs, reported difficulties in managing their workload and ensuring timely care for all residents due to the inadequate staffing levels. Resident #76, who had vascular dementia, psychotic disturbance, and other cognitive impairments, also required significant assistance and supervision. This resident frequently removed his incontinence brief and consumed feces, necessitating constant monitoring and care. On one occasion, Resident #76 was found on the floor next to his bed and was later admitted to the hospital for a possible cranial bleed. The staff reported that the unit was challenging to manage with only two STNAs, as many residents required mechanical lifts for transfers and had complex behavioral health needs. The lack of sufficient staff led to delays in providing care and addressing the residents' needs promptly. Interviews with the nursing staff revealed that the workload was overwhelming, and they often had to forgo breaks to ensure residents received care. The DON and Administrator determined the staffing levels, but the assigned staff was not adequate to meet the needs of the residents on the Rosepointe B unit. The staff's inability to provide timely and appropriate care due to insufficient staffing levels directly contributed to the deficiencies observed in the care of Residents #101 and #76.
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