Failure to Provide Adequate Behavioral Health Interventions and Supervision
Penalty
Summary
A resident with diagnoses of major depressive disorder, anxiety, and schizophrenia was readmitted to the facility following a recent hospital stay. Upon readmission, the resident exhibited escalating behavioral symptoms, including agitation, repeated requests to go to the hospital, verbalization of pain and chest pain, and multiple incidents of moving herself to the floor. Despite these behaviors, staff did not implement a 1:1 sitter intervention, did not adequately monitor or supervise the resident, and failed to document or assess the resident's complaints and behaviors as required by facility policy. Throughout the evening and night, the resident's behavior continued to escalate, with repeated reports from CNAs to LVNs about the resident's agitation, yelling, and requests for hospital transfer. The LVNs did not follow up with the physician for new orders after initial communication, nor did they notify the physician of the resident's ongoing pain complaints, chest pain, or behavioral escalation. There was no evidence of additional interventions or individualized care planning to address the resident's mental health needs or to ensure safety, despite clear indications that the resident's behavior was not being managed and posed a risk to herself and others. The situation culminated in the resident breaking a window, obtaining a large shard of glass, and brandishing it toward her neck while demanding to be sent to the hospital. Emergency services were called, and the resident was transferred to an acute care hospital for a suicide attempt. Interviews and record reviews confirmed that staff did not follow facility policies on behavioral assessment, intervention, monitoring, or change in condition, and failed to provide the necessary treatment and services to attain the highest practicable mental and psychosocial well-being for the resident.