Failure to Provide Comprehensive Behavioral Health Assessment and Person-Centered Planning
Penalty
Summary
The facility failed to implement comprehensive assessment and person-centered planning to ensure that the individualized behavioral health needs of two residents were met. One resident, with diagnoses including alcoholic encephalopathy, PTSD, anxiety, depression, and a history of childhood trauma, was admitted under a court commitment order and required multiple therapies and substance abuse treatment. Despite documented cognitive impairment and a history of trauma, the care plan lacked evidence that the facility identified the resident's responses to stressors or utilized person-centered interventions developed by the interdisciplinary team (IDT). The care plan was not reviewed or revised when interventions were ineffective or when the resident experienced a change in condition related to ongoing abuse. The resident reported feeling unsafe due to harassment and inappropriate sexual advances from another resident, including receiving disturbing notes and being followed in unsupervised areas. These incidents triggered the resident's PTSD symptoms, leading to increased anxiety, sleep disturbances, and emotional distress. The facility's records did not indicate that a comprehensive assessment was completed to determine psychosocial harm, nor were there clear interventions or monitoring systems implemented to ensure the resident's safety or provide supportive services. Family members also expressed concerns about the lack of follow-through on safety plans and the ongoing nature of the harassment. The second resident involved had a history of emotional lability, alcohol use, depression, and anxiety, and was reported by multiple female residents for inappropriate behavior, including writing notes and following them. Staff responses included educating the resident and checking on the affected resident during smoking breaks, but there was no evidence of a comprehensive behavioral health assessment or effective interventions. The facility's trauma-informed care policy outlined the need for individualized interventions and ongoing evaluation, but there was no documentation that these practices were followed in these cases. The facility did not provide additional policies related to behavioral health services.