Failure to Provide Behavioral Health Training and De-escalation Interventions
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of a resident with complex mental health diagnoses, including PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's disease. The resident had active orders for behavior monitoring and multiple psychotropic medications, but there was no documentation of behavior monitoring being completed. The care plan identified the resident's triggers, such as requests to smoke, and noted a history of physical and verbal aggression when these requests were denied. However, there were no documented interventions in place to prevent escalation, and staff were only instructed to attempt to accommodate the resident's requests. On the day of the incident, the resident became agitated after being denied a request to smoke and have a soda outside of scheduled times. Multiple staff, including agency CNAs and an RN, told the resident to wait, which further increased the resident's agitation. The situation escalated when the resident grabbed a CNA, and another CNA responded by striking the resident in the eye. Staff did not attempt any de-escalation interventions or offer alternative options to address the resident's agitation, despite being aware of the resident's triggers and behavioral history. Interviews with staff revealed that there was no formal behavioral health or de-escalation training provided, especially for agency staff, who were only required to read a manual and sign a sheet without any monitoring or verification. The DON and staff confirmed the lack of mental health training and guidance for managing residents with behavioral health needs. Law enforcement also noted repeated issues at the facility related to staff decisions that aggravated residents with mental health conditions.