Failure to Provide Behavioral Health Services and Monitoring for Resident with Self-Harm History
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a known history of self-harm, as required by federal regulations and the resident's PASRR assessment. Despite clear documentation of the resident's extensive psychiatric diagnoses—including schizophrenia, bipolar disorder, borderline personality disorder, and a history of self-harm and suicide attempts—the facility did not consistently implement recommended intensive monitoring or individualized interventions. The resident experienced multiple incidents of self-harm, such as cutting with broken glass and razor blades, hitting walls, and banging their head, resulting in injuries that required emergency medical attention. These incidents were not consistently followed by updates to the care plan or the implementation of new interventions to address the resident's triggers or supervision needs. Staff interviews revealed a lack of awareness regarding the resident's behavioral health history, triggers, and required interventions. Several staff members were unaware of the resident's history of self-harm or the need for one-to-one monitoring, and some had not reviewed the care plan or received relevant behavioral health training. The facility's own policy required intensive or one-to-one monitoring for residents at risk of self-harm, but documentation showed inconsistent application of these measures, with periods where the resident was not under required observation despite recent incidents. Additionally, the care plan was not updated after repeated self-harm events, and did not include interventions related to supervision, known triggers, or parameters for pharmacological interventions. The resident's medical record lacked evidence of trauma-informed services, positive behavioral support, counseling, or other behavioral health services as indicated in the PASRR and required by the care plan. There was no documentation of daily living skills training, structured environment, or socialization supports. The failure to provide these services and to ensure staff were knowledgeable about the resident's needs resulted in repeated self-harm incidents and multiple hospitalizations for the resident.