Failure to Provide Appropriate Behavioral Health Services and Medication Management
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to residents with mental disorders, psychosocial adjustment difficulties, and histories of trauma. For one resident, who was a hospice patient with a history of trauma, the facility did not involve the family in the comprehensive admission assessment and failed to administer medications ordered for paranoia and agitation in a timely manner. The resident exhibited escalating behaviors, including physical aggression towards staff and other residents, but the facility did not incorporate the resident's preferences or trauma history into the care plan. Additionally, there was no evidence that psychiatric services were sought, despite the facility's stated ability to care for residents with complex psychiatric needs. The clinical record showed that the resident's behaviors were not effectively managed, and staff responses included physical interventions that resulted in injury to the resident. Medication orders for antipsychotic and anxiolytic medications were delayed in being added to the medication administration record (MAR) and were not administered as prescribed, even when the resident was exhibiting ongoing behaviors. The facility also failed to communicate and collaborate effectively with hospice staff, who reported that their offers to assist in managing the resident's behaviors were declined, and that the facility proceeded with a 30-day discharge notice based on the resident's psychiatric history rather than current behaviors. For another resident, the facility did not follow up on a Pre-admission Screening and Resident Review (PASARR) that recommended inpatient psychiatric hospitalization due to psychiatric instability. The resident remained in the facility without a psychiatric evaluation for inpatient treatment, despite ongoing symptoms such as hallucinations, delusions, threats towards others, and suicidal ideation. The facility did not take immediate action to ensure the safety of other residents after threats were made, and there was a lack of documentation and communication regarding these incidents. Both cases demonstrate failures in assessment, care planning, medication management, and coordination of behavioral health services for residents with significant mental health needs.