Failure to Provide Appropriate Behavioral Health Services
Penalty
Summary
Facility staff failed to provide clinically appropriate services to a resident with a history of dementia, depression, and anxiety, who exhibited significant behavioral health symptoms. The resident, who was moderately cognitively impaired, was documented as experiencing persistent mood disturbances such as trouble sleeping, feeling down, and difficulty concentrating nearly every day. The resident also regularly rejected care, including medications and activities of daily living, and expressed beliefs that staff were giving him the wrong medications and did not treat him fairly. Despite these ongoing issues, care plan interventions such as assigning familiar staff were not consistently implemented or reevaluated, and there was no evidence that interventions addressed the resident's specific beliefs or resulted in improved mental or psychosocial functioning. Additionally, the psychiatric provider was not informed of the resident's medication noncompliance, and documentation failed to reflect any adjustment or effectiveness of interventions. The resident's agitation escalated to the point where police were called due to threatening behavior, and interviews revealed ongoing distress and paranoia. Facility leadership did not provide comments or concerns regarding these findings during the final interview.