Failure to Provide Person-Centered Behavioral Health Services and Supervision
Penalty
Summary
The facility failed to provide necessary behavioral health care and services that were person-centered and reflected the resident's goals for care, specifically for one resident with a history of hemiplegia, hemiparesis, and dementia. This resident was observed multiple times wandering unsupervised in hallways and other units, taking food from other residents' trays and rooms, and displaying aggressive behaviors such as hitting and making threatening gestures. Other residents and staff reported ongoing distress and complaints about these behaviors, noting that staff responses were limited to redirection and explanations rather than increased supervision or intervention. Interviews with residents, staff, and social services personnel revealed that the underlying causes of the resident's behaviors were not clearly understood or documented in the care plan. The care plan included general interventions such as providing supervision and offering assistance, but observations showed that these measures were inconsistently implemented. Staff and social services acknowledged the need for more supervision and indicated that referrals to psychiatric services were delayed or not current, with the last psychiatric evaluation dated two years prior. Facility policy required the provision of medically related social services and timely referrals for mental and psychosocial counseling, but documentation and interviews indicated that these processes were not effectively followed. The lack of timely psychiatric evaluation, insufficient supervision, and inadequate person-centered behavioral interventions contributed to ongoing behavioral issues that affected both the resident and others on the unit.