Failure to Address and Monitor Behavioral Health Needs
Penalty
Summary
The facility failed to adequately identify, implement, and monitor the behavioral care needs of a resident with a history of post-traumatic stress disorder, traumatic brain injury, and severe cognitive impairment. Despite documentation in the resident's medical records and care assessments indicating significant cognitive and behavioral challenges, including confusion, disorientation, and use of multiple psychotropic medications, the care plan lacked specific interventions to address the resident's wandering, behavioral episodes, and issues with other residents entering his room. Multiple behavior notes in the electronic medical record documented repeated incidents of wandering, aggression, yelling profanity, throwing items, and urinating in inappropriate areas. These behaviors disturbed other residents and led to complaints. Staff interviews confirmed that the resident had exhibited aggressive and wandering behaviors, and that there were ongoing concerns about another resident entering his room and handling his belongings, which upset him. Observations showed that staff were not consistently present to monitor or intervene when the resident or others engaged in problematic behaviors. The facility's own policy required comprehensive assessment and behavioral interventions for residents in need, but these were not fully implemented or monitored for this resident. As a result, the resident was at risk for continued behavioral episodes and unmet care needs.