Failure to Provide Necessary Behavioral Health Services and Person-Centered Care
Penalty
Summary
Facility staff failed to provide necessary behavioral health care and services to a resident with complex medical and psychiatric diagnoses, including major depressive disorder, traumatic brain injury, vascular dementia with psychotic disturbance, and a personal history of suicidal behavior. The facility did not involve the resident's family or hospice team in the comprehensive assessment, did not develop a care plan with individualized interventions, and did not follow the existing care plan. The resident's preferences, such as involvement of family in care discussions and engagement in music and other activities, were not incorporated into the care plan, and the care plan lacked mention of significant psychiatric and trauma history. The resident exhibited escalating behavioral symptoms, including physical and verbal aggression, wandering, and threats toward staff and other residents. Despite these behaviors, there was no evidence that the facility sought geriatric psychiatric services or made appropriate referrals. Orders for antipsychotic and anxiolytic medications were delayed in being entered onto the medication administration record (MAR), and some medications were not administered as ordered. The hospice team was not effectively included in care planning or crisis management, and their offers to assist were declined by facility staff. The facility also failed to notify or involve the resident's family in key decisions, including discharge planning. The facility ultimately issued a 30-day discharge notice to the resident after learning more about the resident's psychiatric history, without evidence of further behavioral incidents at that time. The discharge was based on the facility's stated inability to meet the resident's needs, despite the facility's own assessment indicating the capacity to care for residents with complex psychiatric and behavioral conditions. Documentation and interviews revealed a lack of individualized, person-centered care planning, insufficient communication with family and hospice, and failures in medication management and behavioral health service provision.