Failure to Provide Necessary Behavioral Health Services After Inappropriate Resident Behavior
Penalty
Summary
The facility failed to ensure that a resident with dementia and depression received necessary behavioral health care and services as required by their comprehensive assessment and care plan. The resident, who had a severe cognitive impairment and a history of depression, exhibited inappropriate sexual behavior towards another resident. Despite this incident being reported to staff and documented, there was no evidence that the psychiatric provider overseeing the resident's care was notified of the behavior. Additionally, there was no documentation that the resident received medically related social services to address or debrief the behavior following the incident. Further review revealed that the facility did not initiate or update a care plan to address the resident's depression or the manifestations of their mental health condition. The psychiatric provider was not kept informed of the resident's behaviors, and there was no documentation that the resident's Power of Attorney was contacted to obtain consent for continued psychiatric services. The lack of communication and documentation resulted in the resident not receiving appropriate behavioral health interventions or follow-up after the incident.