Failure to Implement Individualized Behavioral Health Care Plans and Professional Recommendations
Penalty
Summary
The facility failed to develop and implement individualized behavioral health care plans for two residents with behavioral health needs, specifically neglecting to utilize recommendations from professional psychological services to support sobriety efforts. For one resident with moderate cognitive impairment, depression, and a history of substance use, the care plan acknowledged his desire for sobriety and alternative living arrangements, as well as recommendations from a psychological provider to monitor mood, encourage engagement in meaningful activities, and reinforce strengths. However, facility staff, including the community life coordinator and director of social services, were unaware of or did not implement these recommendations. The resident continued to leave the facility unsupervised, sometimes resulting in hospitalizations, and staff did not actively support his sobriety or address his psychological needs as outlined by the consulting psychologist. Another resident, who was cognitively intact but had a history of substance use disorder, depression, and loneliness, also did not receive an individualized behavioral health care plan that incorporated professional recommendations. Despite documentation from a psychologist recommending harm reduction strategies, increased engagement, and consideration of a private room to support sobriety and mental health, the facility did not implement these interventions. The resident continued to consume alcohol in her room, left the facility unsupervised, and was hospitalized for alcohol intoxication. Staff were aware of her drinking but did not establish a behavioral contract or safety plan, and were not fully informed of the psychologist's willingness to assist with harm reduction or safety planning. Facility policy required care planning interventions to address risks for residents with substance use disorders, including providing diversions, substance use treatment services, and increased monitoring. Despite this, the facility did not follow through with the necessary individualized interventions or incorporate the recommendations from psychological services into the residents' care plans. This lack of action resulted in ongoing substance use, unaddressed behavioral health needs, and repeated incidents of residents leaving the facility unsupervised and requiring hospital care.