Failure to Manage and Document Behavioral Health Needs Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that residents with behavioral health needs received appropriate care and supervision, resulting in unmanaged behaviors that compromised the safety and privacy of other residents. One resident with diagnoses including Schizophrenia, Bipolar Disorder, and a history of sexually inappropriate behavior was found unsupervised in the activity room with another resident, during which an incident of inappropriate sexual contact occurred. Staff did not consistently document the presence or absence of target behaviors as outlined in the care plan, and behavior monitoring was incomplete or inaccurately recorded. Additionally, the facility did not establish or communicate the required level of supervision when a Gradual Dose Reduction (GDR) of psychotropic medication was attempted for this resident. Interviews with staff revealed inconsistent reporting and documentation of the resident's behaviors, including sexually inappropriate comments and verbal aggression. Certified Nursing Assistants (CNAs) and other staff members reported observing behaviors such as cursing, refusal of care, and inappropriate remarks, but these were not always documented or communicated according to facility policy. The care plan for the resident included interventions for monitoring and managing behaviors, but these interventions were not effectively implemented or tracked, leading to a failure in managing the resident's risk to others. A second resident with a history of psychotic and mood disturbances exhibited combative behaviors, including hitting another resident. The care plan for this resident did not provide clear direction regarding the level of supervision required to ensure safety. Staff interviews indicated that while interventions such as removing the resident from situations and de-escalation were used, there was a lack of proactive measures and documentation to prevent incidents. These deficiencies affected multiple residents and were substantiated through record reviews, staff interviews, and direct observation.