Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services as required by its own Behavior Management Program policy. The policy mandates that the interdisciplinary team (IDT) assess, track, and review behaviors that negatively impact residents, conduct clinical record reviews, identify root causes, and discuss interventions and care plan updates in weekly meetings. Despite this, documentation revealed that the resident exhibited multiple episodes of yelling, verbal aggression, threats of self-harm, and physical aggression toward staff and other residents over a six-month period. These behaviors included yelling at staff, making threats, attempting to hit staff, and physically interacting with another resident in a disruptive manner. The resident had a documented history of depression and was prescribed Cymbalta for depression and suicidal thoughts. The Minimum Data Set (MDS) assessments and progress notes indicated ongoing behavioral symptoms, including feelings of depression and multiple incidents of disruptive and aggressive behavior. However, the clinical record lacked evidence that the facility provided, attempted to provide, or arranged for behavioral health services or ancillary support in response to these behaviors. The care plan did not address the need for behavioral health assistance related to the resident's actions and threats, despite repeated incidents and documentation of concerning behaviors. Interviews with facility leadership confirmed that sufficient and timely social services were not provided to meet the resident's behavioral health needs. The lack of appropriate behavioral health interventions and failure to update the care plan in response to ongoing behavioral issues constituted a deficiency in providing necessary care and services to maintain the resident's highest practicable well-being.