Failure to Provide Treatment and Monitoring for Resident with Mental Health Crisis
Penalty
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.