Failure to Provide Behavioral Health Services and Training Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide necessary behavioral health care and services, as well as behavioral health services training, for a resident with significant behavioral health needs. The resident, who was diagnosed with Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, and violent behavior, was severely cognitively impaired and dependent on staff for all activities of daily living. Despite documented care plan interventions instructing staff to ensure safety and re-approach the resident with different staff when physical behaviors occurred, the resident experienced multiple incidents of combative behavior during care, resulting in several skin tears and minor injuries. These injuries occurred during routine care activities such as bedtime care, transfers, and shower preparation, with staff sometimes failing to follow recommended interventions such as walking away or seeking assistance. Additionally, the facility did not have psychiatric services available until after several of these incidents had occurred, and the resident had not yet been seen by the psychiatric nurse practitioner. Staff had not received training on behavioral health or on providing care for residents with behavioral issues. Furthermore, required follow-up procedures were not consistently followed, as some injuries were not reported or investigated according to facility policy, resulting in missed opportunities for skin evaluations and appropriate notifications. The facility's policy on PASRR was not fully implemented, as recommendations from Level 2 screens and significant changes in status were not consistently incorporated into the care plan.