Failure to Ensure Staff Competency for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly after admitting several individuals with complex mental health diagnoses. Despite having a policy requiring all staff, including contracted staff and volunteers, to receive education and training based on resident needs, interviews revealed that no formal training on mental health care had been provided to staff members, including CNAs, LPNs, the Activity Director, the Social Service Director, the ADON/Admission Coordinator, the DON, and the Administrator. Staff consistently reported a lack of preparation and training to care for residents with mental health conditions, and several expressed concerns about their ability to provide appropriate care. The facility's admission process required rapid review and decision-making, with corporate expectations for referral reviews and admission decisions to be made within 15 minutes for medical referrals and within two hours for behavioral referrals. This rushed process led to critical information about residents' mental health diagnoses being overlooked, as seen in the case of a recently admitted resident with bipolar disorder and adjustment disorder. Staff were unaware of the resident's mental health conditions at the time of admission, and the lack of prescribed medications for symptom management was not identified. The Social Service Director and DON both acknowledged that the resident's behaviors, such as stealing, inappropriate use of facilities, and manipulation, were not adequately managed due to insufficient training and screening. Multiple residents with significant psychiatric and behavioral health diagnoses, including schizophrenia, bipolar disorder, psychosis, and anxiety disorders, were admitted without the facility ensuring staff were equipped to address their needs. The facility's own assessment indicated that when unfamiliar conditions arose, the interdisciplinary team was supposed to initiate immediate training and competency checks, but this was not implemented in practice. Staff interviews confirmed that no such training or competencies were completed, and the facility's leadership, including the Administrator and DON, admitted to missing key information during the admission process and lacking the necessary training to support residents with behavioral health needs.