Failure to Provide Necessary Behavioral Health Services for Residents with Ongoing Behavioral Issues
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with significant behavioral and psychosocial needs. One resident with advanced dementia was repeatedly observed engaging in unsafe wandering behaviors, such as entering other residents' rooms, rummaging through belongings, and nearly falling from her wheelchair and bed. Staff reported that this resident frequently cried, wandered, and was the target of negative interactions from other residents, including yelling and having objects thrown at her. Despite these ongoing behaviors, the care plan only included general interventions such as offering reassurance and social services follow-up as needed. Social services staff confirmed they did not actively address the resident's emotional or psychosocial needs, focusing instead on unrelated issues, and there was no documentation of behavioral health assessments or interventions for her continued distress and behaviors. Another resident exhibited frequent verbal and physical aggression, including yelling profanities at other residents, physically threatening staff, entering other residents' rooms, and engaging in inappropriate behaviors such as defecating in another resident's refrigerator. Nursing notes documented multiple incidents of aggression and wandering over several days, with staff reporting that these behaviors occurred nightly and sometimes required security intervention. The care plan for this resident also only referenced general psychosocial support and social services follow-up as needed, without evidence of targeted behavioral health interventions or assessments. Interviews with staff revealed a lack of active involvement from social services in addressing behavioral health issues for both residents. The staff member responsible for behavioral health consultations was unaware of the ongoing behaviors and had not been asked to provide input or interventions. There was no evidence that the facility had assessed or implemented appropriate behavioral health services to address the residents' needs, as required by their comprehensive assessments and care plans.