Failure to Document and Monitor Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with multiple behavioral health diagnoses, including traumatic brain injury, post-traumatic stress disorder, and schizophrenia. Observations showed the resident exhibiting behaviors such as yelling at staff and refusing care, but the clinical record lacked documentation of these behaviors. The resident's care plans for antipsychotic and antidepressant medications included interventions to monitor behavior and mood, yet there was no evidence in the record that these behaviors were being tracked or monitored as required. Interviews with staff, including CNAs and the DON, confirmed that the resident sometimes called staff names, refused care, or isolated himself, but these behaviors were not reflected in the care plan or documented in the clinical record. The facility's own behavioral health management policy required identification, monitoring, and documentation of behavioral events, especially for residents on psychotropic medications, but these procedures were not followed for this resident.