Failure to Provide Resident-Specific Behavioral Health Interventions
Penalty
Summary
The facility failed to provide resident-specific behavioral health interventions for a resident with multiple diagnoses, including congestive heart failure, emphysema, cognitive communication deficit, and a history of substance abuse. The resident exhibited ongoing behaviors such as frequent yelling, refusal of medications and care, and expressions of emotional distress, including being tearful and missing family. Despite repeated documentation of these behaviors and their ineffectiveness to redirection, the care plan did not address these specific behaviors or identify resident-specific stressors. The care plan only included general interventions such as encouraging socialization, providing non-judgmental support, and offering psychiatric services as needed. Staff interviews revealed that the Social Service Director was not aware of the resident's specific behaviors, such as yelling and refusal of medications, until they were noted in behavior logs and report sheets. Regular interdisciplinary team meetings, where new behaviors would typically be reviewed, had not occurred during the week due to the annual state survey. Although the resident had signed up for substance abuse counseling, they refused to participate in the sessions. Facility policy required precise documentation of behaviors and inclusion of identified behaviors in the resident's plan of care, which was not followed in this case.