Failure to Administer Psychotropic Medication and Implement Behavioral Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents. For one resident with a history of stroke and behavioral disturbances, the facility did not administer a prescribed antipsychotic medication via intramuscular injection as ordered by the physician. The resident's care plan specifically included the intervention to administer medications as ordered, and the medication administration record confirmed the dose was missed. The psychiatric nurse practitioner expressed concern about the missed dose due to escalating behaviors observed in the resident. For another resident with diagnoses including depression, anxiety, pseudobulbar affect, and hemiplegia, the facility did not implement the behavioral care plan during an incident involving a staff member. The care plan outlined specific approaches for managing the resident's behavioral outbursts, such as maintaining a calm environment, approaching the resident calmly and individually, and providing reassurance. During the incident, the Maintenance Director and other staff entered the resident's room while the resident was upset, and the Maintenance Director engaged in a confrontational exchange, raising his voice and pointing at the resident. Multiple interviews confirmed that the staff did not follow the outlined behavioral interventions, and the situation escalated, causing distress to the resident. The facility's behavior management policy requires individualized, non-pharmacological interventions and staff education on resident-specific interventions. Despite this policy, the staff involved did not adhere to the prescribed approaches for managing behavioral expressions, resulting in a failure to provide the necessary behavioral health care and services as required.