Failure to Develop and Implement Individualized Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized care plan that identified behavioral triggers and de-escalation needs for a resident with complex behavioral health diagnoses, including paranoid schizophrenia, traumatic brain injury, and polysubstance dependence. Despite documented incidents of aggression, disrobing, entering other residents' rooms, and multiple falls, the care plan lacked specific interventions, triggers, or instructions for staff on how to redirect or manage these behaviors. The resident experienced repeated behavioral episodes, including physical altercations, inappropriate undressing, and property damage, which were not adequately addressed in the care planning process. Staff interviews revealed a lack of consistent behavior management training and limited access to resident-specific behavioral information. Direct care staff, such as CNAs, reported relying on nurses for guidance, as they did not have access to care plans or written instructions regarding behavioral interventions. Some staff indicated that behavior management training was outdated or unavailable, and information about resident behaviors was often communicated verbally rather than documented or accessible in written form. Additionally, there was confusion among staff regarding where to find information about resident triggers and interventions, and some staff reported being told to "stay in their lane" when inquiring about behavioral management. The resident's behavioral health needs were further complicated by medication changes, hospitalizations for behavioral disturbances, and a lack of timely updates to the care plan following significant events such as hospital admissions and returns. Despite recommendations from hospital psychiatry and evidence of acute decompensation related to medication adjustments, the facility did not update the care plan to reflect new interventions or strategies. The absence of a comprehensive, individualized behavioral care plan and insufficient staff training contributed to ongoing behavioral incidents and inadequate management of the resident's physical, mental, and psychosocial well-being.