Failure to Provide Necessary Behavioral Health Care and Individualized Care Planning
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizophrenia, depression, and anxiety disorder, who also had a history of aggressive behavior. The Minimum Data Set (MDS) assessment for this resident did not accurately reflect the resident's history of aggressive physical and verbal behavior, despite multiple documented incidents of aggression and disruption. The care plan for the resident was not individualized or effective, lacking specific interventions, supervision details, and frequency of re-evaluation. There was also a period when no behavior or schizophrenia care plan was in place for the resident. Multiple documented incidents showed the resident displaying aggressive and disruptive behaviors, including provoking other residents, yelling, and physically assaulting staff. On one occasion, the care plan addressing behavior problems was canceled, and for nearly two weeks, there was no care plan in place to address the resident's behavioral health needs. The MDS assessment contradicted the clinical record by indicating the resident did not exhibit physical or verbal behaviors toward others, despite clear evidence to the contrary in the clinical documentation. The lack of an accurate assessment and an effective, individualized care plan led to an incident where the resident entered another resident's room, resulting in a physical altercation. The resident struck another resident in the chest and required administration of multiple medications for aggressive behavior. Staff interviews confirmed that documentation of the resident's behavior was insufficient and that the interventions in place were not appropriate or effective for the resident's needs. Facility policies required comprehensive, person-centered care planning and prompt action to prevent resident-to-resident altercations, but these were not followed in this case.