Failure to Provide Behavioral Health Services Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with a history of psychiatric and behavioral health needs received appropriate behavioral health evaluation and services upon admission. The resident was transferred from another skilled nursing facility with diagnoses including stroke and depression, and had a documented history of Bipolar II disorder and recent psychology appointments. However, upon admission, the facility did not validate or reassess the previous PASRR, which had not identified serious mental illness or psychotropic medication use, nor did they recognize the resident's ongoing mental health needs as indicated in the transfer records and initial assessments. Despite the resident's moderate cognitive impairment and mild depression identified on the MDS and PHQ-9, there was no behavioral health care plan developed, and no mental health appointments were provided after admission. The DON confirmed that the admission team did not identify the resident's Bipolar II disorder or prior psychological care, and the Social Services Director stated that the PASRR from the previous facility was not validated for accuracy. The lack of behavioral health interventions and follow-up contributed to the resident's escalating behavioral symptoms, including aggression, threats of self-harm, and agitation. These unaddressed behavioral health needs culminated in multiple incidents, including threats to staff, self-injurious behavior, and a resident-to-resident altercation where the resident shoved another resident out of a wheelchair. The situation escalated to the point where the resident required 1:1 monitoring and was ultimately transferred to the hospital for psychiatric evaluation after repeated self-harm attempts and aggressive behavior, despite being under continuous observation.