Failure to Provide Individualized Behavioral Health Services for Residents with Mental Disorders
Penalty
Summary
The facility failed to provide individualized treatment and services to two residents with mental disorders, resulting in repeated incidents of verbal, manipulative, and aggressive behaviors. For one resident, there were multiple documented episodes of inappropriate conduct, including smoking in prohibited areas, taking items from other residents, making sexually inappropriate comments and advances toward both staff and other residents, and causing property damage such as flooding a room by tampering with plumbing. Despite these behaviors and a documented history of mental health diagnoses including bipolar disorder, adjustment disorder, and anxiety, the facility did not implement meaningful non-pharmacological interventions, alternate strategies, or timely psychiatric services. The care plan primarily focused on education and redirection, with little evidence of increased supervision or specialized behavioral health interventions, even after repeated grievances and incidents involving other residents and staff. Another resident with a history of paranoid delusional disorder, substance-induced mood disorder, and recent incarceration for psychiatric reasons also exhibited challenging behaviors, including verbal abuse, hallucinations, wandering, and repeated requests for cigarettes. The resident's PASARR Level II evaluation indicated a need for ongoing psychiatric and mental health follow-up, close supervision, and a structured environment to address active psychosis and elopement risk. However, the facility's documentation showed a lack of consistent behavioral health services, monitoring, or trauma-informed interventions tailored to the resident's needs. Behavioral symptoms were noted, but the care plan did not reflect the level of psychiatric oversight or crisis intervention recommended in the evaluation. Interviews with staff revealed a lack of formal mental health training and uncertainty about how to manage residents with complex behavioral health needs. The Social Service Designee admitted to not having received mental health training and being unsure of appropriate interventions. The facility's approach to managing these residents relied heavily on education and redirection, without escalation to specialized services or increased supervision, even after significant incidents and grievances. There was no evidence of psychiatric services being provided or additional monitoring being implemented, despite ongoing behavioral issues and risks to other residents and staff.