Failure to Provide Behavioral Health Services for Resident with Ongoing Behavioral Issues
Penalty
Summary
The facility failed to provide appropriate behavioral health services to a resident diagnosed with depression and exhibiting ongoing behavioral issues. The resident had a documented history of depression, was prescribed Cymbalta for depression and suicidal thoughts, and had multiple documented incidents of yelling, verbal aggression, threats of self-harm, and physical aggression toward staff and other residents over a six-month period. Despite these behaviors, the facility's clinical record lacked evidence that behavioral health services were provided, attempted, arranged, or requested for the resident. The facility's Behavior Management Program policy required assessment, tracking, and interdisciplinary review of behaviors negatively impacting residents' quality of life, including documentation, root cause analysis, and care plan updates. However, review of the resident's care plan showed it did not address behavioral health assistance related to the resident's actions and threats, including self-abuse, physical and verbal abuse, and threats to others. Progress notes and social services documentation indicated repeated behavioral incidents, but interventions were limited to brief check-ins and did not include referrals or engagement with behavioral health professionals. Interviews with facility leadership confirmed the failure to ensure the resident received appropriate behavioral health services to maintain their highest practicable well-being. The deficiency was identified through review of facility policy, clinical records, and staff interviews, and was cited under relevant state regulations for management and nursing services.