Failure to Provide Behavioral Health Services for Resident with Severe Behavioral Symptoms
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with severe cognitive impairment and a diagnosis of dementia, who exhibited frequent and escalating physical and sexual behavioral symptoms directed toward staff and others. Documentation in the resident's medical record and progress notes detailed multiple incidents over several months, including inappropriate touching, grabbing, verbal aggression, and sexual advances toward staff during care and transfers. Despite these ongoing behaviors, there was no evidence that the resident received any behavioral health assessment or intervention from outside behavioral health services. Interviews with facility staff, including the Social Services Designee, NHA, LPN, and DON, confirmed that the resident had not been seen by behavioral health professionals, and staff were either unaware of or had not initiated referrals for behavioral support. The facility's own policy required the provision of behavioral health services as needed, but no such services were provided for this resident, as confirmed by staff statements and the absence of documentation in the medical record.