Failure to Provide Behavioral Health Services and Documentation
Penalty
Summary
The facility failed to provide necessary behavioral health care services to a resident with a complex medical and psychiatric history, including vascular dementia, mood and psychotic disturbances, and anxiety. Observations revealed the resident frequently yelled out and hit her leg, behaviors that were not addressed through behavioral health interventions. The resident was unable to communicate about her care, and her care plan identified ongoing behavioral issues such as screaming, banging, and agitation, with interventions to monitor and document behaviors and attempt to determine underlying causes. However, there were no physician orders for behavior monitoring, and no documentation of behaviors was found in the Treatment Administration Record or progress notes. Interviews with staff indicated uncertainty about the need to monitor or document the resident's behaviors, and the DON described the behaviors as a form of communication rather than behavioral health issues. Despite the facility's policy requiring person-centered behavioral health services and documentation, there was no evidence that the resident's behaviors were being consistently monitored, documented, or addressed through appropriate behavioral health care services.