Failure to Implement Effective Behavioral Interventions for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to implement effective behavioral interventions for a resident with multiple mental health diagnoses, including anxiety disorder, severe intellectual disabilities, unspecified mood disorder, insomnia, and impulsiveness. The resident exhibited behaviors such as wandering, intruding on others' privacy, and inappropriate touching, as documented in the electronic health record and care plans. Despite being placed on 1:1 monitoring due to these behaviors, the interventions outlined in the care plan, such as immediate redirection and staff assistance in developing appropriate coping methods, were not consistently followed. Multiple progress and behavior notes indicated ongoing incidents where the resident was not easily redirected, ignored staff attempts to assist, and continued to display inappropriate behaviors, including loud outbursts, foul language, and attempts to touch staff and other residents. Specific incidents included the resident touching a female resident inappropriately, grabbing and hugging a female surveyor without staff intervention, and repeatedly grabbing a CNA's arm without being redirected. Staff interviews confirmed that the 1:1 monitoring was implemented due to the resident's inappropriate behaviors, but staff did not always intervene or redirect the resident as required. Additionally, the facility was unable to provide a policy for behavioral management when requested. The lack of consistent staff intervention and absence of a behavioral management policy contributed to the facility's failure to provide necessary behavioral health care and services, placing the resident at risk for mental anguish, social isolation, and impaired quality of life.