Failure to Provide Behavioral Health Services and PASRR Assessment
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident who exhibited frequent disruptive and dangerous behaviors, including yelling, cursing, threatening staff and other residents, and using illicit substances. The resident's behaviors escalated to physical violence, including punching a roommate, displaying a knife, and making threats to kill. Despite these incidents, there was no evidence that a comprehensive behavioral management program was implemented as required by the facility's own policy. Documentation showed that staff did not consistently assess, monitor, or evaluate the effectiveness of interventions, and there was a lack of ongoing psychiatric support, with no documented psychiatric visits for two months. The resident had a documented history of substance abuse, including recent cocaine use, and multiple hospital admissions for related health issues. The initial assessments and care plans did not adequately address the resident's substance use or behavioral health needs. The care plan focused primarily on smoking safety and oxygen therapy, with minimal attention to behavioral management or substance abuse interventions. Staff interviews revealed a lack of awareness regarding the resident's substance use history and uncertainty about whether federally mandated Pre-admission Screening and Resident Review (PASRR) was completed, which is required for residents with serious mental illness or substance use disorders. Throughout the resident's stay, there were repeated incidents of verbal and physical aggression, including threats and altercations with staff and other residents. Interventions such as one-to-one monitoring and police involvement were only implemented after significant escalation. The facility's failure to identify, assess, and address the resident's behavioral health and substance use needs, as well as the lack of a documented PASRR, contributed to ongoing safety risks for the resident and others. The deficiency was further compounded by inadequate interdisciplinary collaboration and incomplete documentation of behavioral incidents and interventions.