Failure to Provide Consistent Behavioral Health Services and Update Care Plans After Resident Aggression
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a known history of physical aggression, PTSD, dementia, and wandering. Despite the resident's documented behavioral health needs and repeated incidents of aggression towards other residents, the facility staff did not consistently implement or update individualized care plans with new interventions after each behavioral incident. The care plan lacked timely updates and did not reflect changes in the resident's condition or the effectiveness of interventions, even after multiple altercations and hospitalizations. Staff interviews and record reviews revealed that the interdisciplinary team (IDT) was not consistently involved in assessing the resident's behavioral needs or in developing and implementing new strategies following each incident. Documentation was incomplete regarding IDT meetings, staff training on behavior management, and the identification of triggers or effective interventions for the resident. Staff often relied on one-on-one observation or sending the resident to the hospital, rather than developing and applying individualized, non-pharmacological interventions as outlined in facility policy. The resident continued to display aggressive behaviors, including entering other residents' rooms, taking food, and physically striking or attempting to strike other residents. These behaviors resulted in repeated emergency room visits, hospitalizations, and ultimately transfer to a psychiatric facility. The facility's failure to provide consistent, person-centered behavioral health care and to update care plans and interventions after each incident contributed to ongoing safety concerns for both the resident and others.