Failure to Provide Behavioral Health Services and De-escalation for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with severe mental illness, including PTSD, major depressive disorder, traumatic brain injury, and Alzheimer's disease. The resident, who is their own responsible party, exhibited agitated and aggressive behaviors when denied requests to smoke and have a soda outside of scheduled times. Staff, including agency personnel, did not attempt to de-escalate the situation or offer alternative options, despite being aware of the resident's triggers. Instead, staff repeatedly told the resident to wait, which further increased agitation, ultimately resulting in the resident physically grabbing a CNA, and the CNA responding by striking the resident in the eye. The facility did not provide documentation of required behavior monitoring, despite physician orders for such monitoring every shift. There were also no documented interventions in the care plan to prevent escalation of behaviors, and the facility lacked a policy on behavioral health management. Staff interviews revealed that there was no formal training on mental health disorders or de-escalation techniques, and agency staff were only required to read a manual without any verification or monitoring of their understanding. The DON and RN involved acknowledged the lack of formal training and the absence of alternative interventions offered during the incident. Law enforcement and the medical director confirmed the incident, with law enforcement noting that staff actions often instigated residents with mental health issues by denying requests, leading to aggressive reactions. The medical director stated that staff should never hit a resident, regardless of the situation. The facility did not provide a PASRR for the resident, and there was no evidence of a behavioral health management policy or adequate staff training to address the needs of residents with mental health disorders.