Failure to Provide Treatment and Monitoring for Resident with Mental Health Crisis
Summary
A resident with diagnoses of depression, anxiety, and borderline personality disorder was identified as being a danger to self and others (DTSO) after verbalizing intentions to harm self and others. Despite a physician's order for transfer to a general acute care hospital (GACH) and recommendations for psychiatric and psychological consultations, the resident refused these interventions. The facility failed to implement 1:1 sitter observation, did not monitor or document the resident's behavior after being identified as DTSO, and did not develop or implement a care plan to address the resident's refusal of transfer or psychiatric consultation. There was no evidence in the medical record that the facility monitored the resident's behavior or provided additional interventions after the resident refused psychiatric consultation. Staff interviews confirmed that no hourly monitoring, documentation, or care planning was initiated following the resident's refusal of transfer and ongoing verbalizations of self-harm or harm to others. The interdisciplinary care team did not meet to address the situation, and there was no documentation of behavioral observations or safety interventions in the resident's chart during the period of risk. As a result of these failures, the resident was later found unresponsive in their room with opened prescription medication containers not dispensed by the facility. The resident was transferred to the hospital via emergency services, where toxicology confirmed an intentional overdose of tricyclic antidepressants. The resident required intubation and admission to the intensive care unit. The facility's lack of assessment, supervision, monitoring, and care planning for a resident identified as DTSO directly preceded this critical incident.
Removal Plan
- The charge nurse will immediately notify the physician if the resident refused to go to the hospital, refusal of care and treatment for psychiatry and psychologist.
- If a resident has an order to be transferred to the hospital for further evaluation who exhibits any behavior, and refused to be transferred to the hospital licensed nurse will immediately notify MD.
- The Director of Social Services completed a Psychosocial Assessment of identified residents who has a diagnosis of depression, reviewed and updated Care Plan as necessary.
- Licensed staff were instructed to document behavioral observations in the monitoring log such as DTSO every hour and notify the nurse or RN supervisor and/or designee.
- The Medical records Director generated an audit of all residents with diagnoses including anxiety disorder, borderline personality disorder, and Depression; and provided the list to the Assistant Director of Nursing (DON) and the Administrator for further review and analysis.
- The Director of Social Services completed a psychosocial assessment of all residents with a diagnosis of depression to identify residents who may be DTSO and no other residents were identified at risk of harming themselves or others.
- Situation, Background, Assessment, and Recommendation (SBAR) / Change in Condition (COC) was implemented, and in-service was conducted by Assistant DON and Clinical Consultant to licensed nurses that the facility promptly notifies the resident, the resident's physician and the resident's representative of any changes in the resident's medical/mental condition and/or status.
- 72-hour monitoring including mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations will be implemented for the resident/s. The Assistant DON and clinical consultant conducted an in-service to licensed nurses to include mood/behavioral changes, interactions with staff and peers, response to redirection, and safety observations.
- The care plan was reviewed and updated for identified residents who has a diagnosis of depression. Assistant DON and clinical consultant provided in-service to license nurses regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer for resident's safety.
- The Administrator conducted 1:1 in-service to SSD regarding Care plan documentation for residents that addressed a psychiatric crisis and refusal to comply with the physician's recommendation for hospital transfer to ensure resident's safety.
- Crisis Intervention Plan included: Provide safe and clean environment; Visual check and document monitoring of resident behavior every hour for resident safety; Administer medication as ordered; Diet as ordered; Encourage to verbalize feelings; Always approach in calm and friendly manner and unhurriedly; To ensure all needs are met; Provide emotional support; Maintain comfort and dignity; To call doctor of medicine (M.D) for any noted change of condition.
- Social Services will re-evaluate and update initial psychosocial assessment of the resident when a resident refused for psychiatric consult and licensed nurse will inform MD.
- Social services will make daily visits to re-engage the resident and residents who are identified with diagnosis of depression, anxiety and borderline personality disorder and documented in the progress notes and provide resident's education on the importance of psychiatric evaluation.
- Behavioral and Crisis intervention care plan will be implemented to reflect ongoing risk for harm to self and others. Interventions included: PRN and scheduled psychiatric medication management; Behavior tracking and psychiatric consultation follow-up; Staff re-education on management of residents with psychosocial adjustment difficulties; Development of a crisis intervention care plan to Resident 1's behavior that triggers and de-escalation techniques.
- The ADON and Clinical consultant conducted in-service licensed nurses regarding policy and procedure SBAR/COC with emphasis on immediately reporting resident for any change in the resident medical/mental condition.
- Licensed staff in-services will continue until compliance is met.
- All licensed nurses and social services staff were in-serviced by Administrator, ADON and Clinical consultant regarding the existing policies and procedures: Charting and Documentation Policy for management of residents with psychiatric/psychologist who has a diagnosis of depression, anxiety, borderline personality disorder and danger to self and others; Requesting, Refusing and/or Discontinuing Care or Treatment; Initial Psychosocial Assessment, Intervention and Monitoring Policy and Implementation of Crisis Intervention Policy.
- The Director of Nursing (DON) and/or ADON will audit all residents with behavioral risks for residents who have diagnosis of depression, anxiety, borderline personality disorder and danger to self and others weekly x 4 weeks, then monthly x 3 months.
- All refusals of psychiatric care or hospital transfers will be reviewed by the IDT within 24 hours of occurrence and to notify primary care physician.
- Results of audits and compliance monitoring will be reported by the DON and/or ADON monthly to the Quality Assurance and Performance Improvement (QAPI) committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who suffered a traumatic resident-to-resident assault with a head injury and intracranial bleeding continued to report fear that the other resident would enter her room again. The record showed the other resident had repeated room-entry and agitation issues, but there was no documentation of psychosocial monitoring for the affected resident after the incident, despite later anxiety and agitation noted in the chart.
A resident with TBI, stroke-related deficits, depression, and anxiety repeatedly displayed verbal aggression toward a former roommate, including threats, profanity, and blocking the other resident’s path in common areas. Although staff separated the residents at times and the resident was later sent to the ED for an aggressive reaction, the care plan did not identify the ongoing aggression toward the specific resident or include targeted interventions, and staff interviews showed inconsistent awareness and poor communication about the conflict.
Failure to Monitor and Document Behavioral Symptoms: A resident with dementia with agitation and Alzheimer’s disease had physician-ordered monitoring for agitated behaviors and non-pharmacological interventions, but staff did not consistently document his behaviors or interventions. The resident had a history of choking his wife, later misidentified and attempted to kiss a female resident, and entered another resident’s room where he allegedly kissed or attempted to kiss one resident and threatened the other. He was also observed unsupervised, walking the halls and interacting with other residents, and the DON confirmed the care plan and MD orders were not implemented for behavioral health management.
A resident with stroke, anxiety, and mild neurocognitive disorder with behavioral disturbance had escalating verbal aggression, threats, refusal of care, and statements suggesting paranoid or delusional thoughts. The care plan addressed verbal aggression, but the record showed worsening depression-related findings, repeated behavioral incidents, refusal of behavioral health services and other care, and recent self-mutilating behaviors. The DON acknowledged that a significant change PASARR probably should have been completed, while the SSD reported limited involvement beyond BIMS and PHQ screening.
Failure to provide appropriate behavioral health monitoring and services: two residents with significant psychiatric histories and behavioral care plans did not receive adequate oversight or timely provider notification. One resident assaulted a roommate, then was left with one-on-one monitoring that was not maintained within line of sight while the resident yelled, pounded on walls, and became increasingly agitated; another resident had repeated behavioral emergencies and aggression after an antipsychotic dose reduction, but staff did not adequately monitor the resident or promptly notify the psychiatric provider.
Delayed Psychiatric Services: A resident with neurocognitive disorder with Lewy bodies, psychosis, and anxiety had psych consult orders that were not completed in a timely manner. Staff reported the delay was related to obtaining consent from the wife, limited psych NP availability, vacation coverage gaps, and caseload prioritization, resulting in the resident not being seen by psych until well after the orders were placed.
Failure to Address Psychosocial Impact After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a resident who experienced a traumatic event received appropriate treatment and services after a resident-to-resident physical abuse incident that resulted in major injury. Resident #65, who was cognitively intact with a BIMS of 14, was found lying on the floor in the doorway to her room with bleeding from a head wound after Resident #42 was found in her room holding her iPad and a struggle occurred. Resident #65 was transferred to the ED, where trauma imaging showed an acute medial right frontal lobe multifocal subarachnoid hemorrhage with parafalcine and right tentorium subdural hematoma measuring up to 5 mm, with no midline shift. After the incident, Resident #65 reported ongoing fear that Resident #42 would enter her room again, stating staff took the other resident away when she came in and that she was afraid and had to watch her. The record showed Resident #42 had a pattern of entering other residents’ rooms, agitation, combativeness, and interpersonal conflict, with CPS recommending redirection, re-orientation, structured environment, and limited overstimulation. Resident #65’s notes documented denial of needs on one date and denial of psychosocial needs at a later social work visit, and no additional documentation of psychosocial monitoring was found. The resident later had increased anxiety with Buspar ordered and was verbally agitated with staff, while the care plan only addressed the subdural hemorrhage and monitoring for mental status changes and abnormal findings.
Failure to Address Ongoing Verbal Aggression Between Two Residents
Penalty
Summary
The facility failed to ensure that a resident with a traumatic brain injury, stroke-related deficits, depression, anxiety, and intermittent irritability received appropriate treatment and services to support mental and psychosocial well-being. The resident had a history of becoming verbally aggressive toward a former roommate, including threatening to beat the roommate and using profanity toward the roommate in common areas. The resident’s care plan identified general irritability, depression, anxiety, and the need to observe mood and notify the physician of changes, but it did not identify the resident’s repeated verbally aggressive behaviors toward the former roommate or include specific interventions to address those behaviors. After an initial incident in which the resident threatened the former roommate in the dining room, staff separated the residents for the rest of the day, but the care plan was not updated to reflect the behavior or targeted interventions. A later behavior management evaluation documented another episode in which the resident expressed an intent to harm the other resident, and staff notified the RN and the resident’s family. The resident was later sent to the emergency department after another confrontation involving the former roommate, where the resident had blocked the other resident’s path, used profanity, and was diagnosed with an aggressive reaction and given hydroxyzine. The resident continued to display verbally aggressive behavior toward the former roommate after these events, including cursing at the resident in the dayroom and refusing to move away when directed by staff. The care plan remained general and continued to describe irritability, staring triggers, limited abilities, poor safety awareness, and impulsivity, but still did not identify the ongoing aggression toward the former roommate or specific interventions for that behavior. Staff interviews reflected inconsistent awareness of the ongoing conflict, with some staff stating there were no further issues and others stating the problem was ongoing and communication between shifts was poor. The physician and family member both described the residents as not getting along, and the physician stated staff should monitor them like other residents, while the facility administrator stated she would not expect the care plan to contain specific interventions related to the other resident.
Failure to Monitor and Document Behavioral Symptoms
Penalty
Summary
The facility failed to implement physician-ordered monitoring and documentation of agitated behaviors and non-pharmacological interventions for a resident with dementia with agitation, Alzheimer’s disease, and a history of colon and prostate cancer. The resident’s MDS showed cognitive impairment, and a physician’s order dated February 18, 2026 directed staff to monitor and document agitated behaviors and attempted interventions every day and on every shift. The care plan also included interventions to engage the resident in structured activities and to observe, document, and report behavioral changes to the physician. Facility documentation showed that after the resident was admitted following an incident in which he choked his wife at home, he later misidentified a female resident as his wife, attempted to kiss her, and followed her until staff intervened, which led to his move to another floor. On July 16, 2026, he entered the room of two residents without invitation, allegedly kissed or attempted to kiss one resident without consent, and threatened the other resident with bodily harm when objected to. Review of documentation from June 27, 2026 through July 27, 2026 showed no evidence that his behavior was monitored and documented for 22 of 30 days, including July 16, 2026. During observation on July 27, 2026, he was seen unsupervised interacting with other residents, walking the halls independently, and sitting alone at a window, and the DON confirmed that the physician’s orders and care plan were not implemented for behavioral health management.
Failure to Provide Behavioral Health Services for Resident With Escalating Behavioral and Psychosocial Needs
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to a resident with diagnoses including stroke, generalized anxiety disorder, and mild neurocognitive disorder with behavioral disturbance, in order to assist him in achieving his highest practicable mental well-being. The facility policy required behavioral health care and medically-related social services based on comprehensive assessment and care planning, with behavior tracking and interdisciplinary assessment when behaviors or mood changes posed concerns. The resident’s care plan identified verbal aggression related to frustration with his family, with an intervention to monitor behavior episodes and determine underlying causes, but the record showed escalating behavioral concerns without documentation of a significant change PASARR assessment. The resident’s annual MDS documented little interest in doing anything and feeling down, depressed, or hopeless almost daily, along with rejection of care for one to three days out of seven and worsening behaviors since the prior assessment. Progress notes documented repeated verbal aggression, profanity, threats toward a visitor, and statements that staff were covering things up. He also made statements suggesting paranoid or delusional thoughts, including saying a nurse put something in his water and accusing staff of lying and drug use. The record also reflected refusal of medications, behavioral health services, insulin, and at times dialysis, along with recent documentation of self-mutilating behaviors. During interviews, the DON stated the resident had made other comments about dependent residents and had recent self-mutilating behaviors. The SSD stated she was not really involved in behavior management beyond BIMS and PHQ screening and described the resident as acting out more since returning from maternity leave. The Administrator stated the resident was aggressive, that the facility had tried counseling and family involvement, and that he had burned too many bridges. In a follow-up interview, the DON acknowledged that a significant change PASARR probably should have been completed and stated the staff were not documenting the delusions themselves, while also noting that the resident’s behaviors and self-mutilating behaviors had increased.
Failure to Provide Appropriate Behavioral Health Monitoring and Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents with mental disorders and behavioral health needs. One resident had diagnoses including bipolar disorder with psychotic features, schizoaffective disorder, depression, a history of substance abuse, prior suicide attempts, poor insight and judgment, impulsive behavior, and a care plan calling for close monitoring, coping skills, and notification of the physician for new behaviors. After a conflict with a roommate, the resident assaulted the roommate during a room move, causing the roommate to sustain an abrasion to the lip, scratches to the chest, and red marks around the neck. The resident was placed on one-on-one monitoring after the altercation, but staff were observed outside the room with the door closed while the resident yelled, pounded on the walls, and used profanity, and one assigned staff member was later found asleep on the floor outside the room. The same resident’s care plan and facility policies called for close behavioral monitoring, use of coping skills, de-escalation, and physician notification for behavioral changes. However, staff did not adequately monitor the resident when behaviors escalated, did not keep the resident within line of sight as required by the monitoring plan, and did not timely notify the psychiatric provider when the resident was yelling, hitting the walls, and displaying increased agitation. Interviews showed staff were unsure how far the behaviors had to go before calling a Code Green, and one staff member stated he or she opened the door only about every hour. The psychiatric provider stated staff should not have left the resident alone in the room with the door closed while the resident was yelling and hitting the wall. A second resident had a history of chronic mental illness, suicidal ideation, aggressive behavior, impaired judgment, impaired impulse control, and medication non-compliance. After a psychiatric medication reduction, the resident had several behavioral emergencies, aggressive behaviors, and an attempted assault on another resident, during which the resident injured an ankle and fell. The record showed the psychiatric provider expected close monitoring for recurrence of mood swings, irritability, insomnia, anxiety, psychosis, behavior changes, and safety concerns, but the facility did not adequately monitor the resident or timely notify the psychiatric provider when the resident continued to have behavioral emergencies and aggression.
Delayed Psychiatric Services
Penalty
Summary
The facility failed to ensure psychiatric services were provided timely and according to orders for one resident with neurocognitive disorder with Lewy bodies, psychosis, and anxiety. The resident’s quarterly MDS showed severely impaired cognition, dependence for all ADLs, and bowel and bladder incontinence. The medical record showed orders for psych services on 04/10/26 and again on 05/03/26, but the resident was not seen by psych until 06/28/26. The delay was discussed in interviews with facility staff. The DON stated the delay was related to obtaining consent from the wife and confirmed the psych consult orders. SSD stated verbal consent from the wife was not received until the care conference on 05/25/26 and was unsure why psych did not see the resident sooner after that. SSD also stated the psych NP only comes to the facility every two weeks and was on vacation with no coverage. The psych NP acknowledged awareness that the resident was not seen for approximately one month after consent to treat was received and stated new referrals are sometimes pushed back based on caseload.
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