Failure to Address and Manage Resident Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of encephalopathy, epilepsy, hemiplegia, hemiparesis, unspecified moderate dementia with behavioral disturbance, anxiety disorder, and insomnia. The resident exhibited severe cognitive impairment and demonstrated frequent behavioral symptoms, including yelling, screaming, kicking, hitting, grabbing, and rejection of care over multiple days. Despite these ongoing behaviors, the facility did not initiate a care plan focus area addressing the potential for physical aggression or implement specific interventions to guide staff response until after a significant incident occurred. On one occasion, while a CNA was providing care, the resident became combative, resulting in the resident's head hitting the wall and sustaining a swollen right eye and a laceration above the eye. Prior to this incident, there were no documented interventions in the care plan instructing staff on how to respond to the resident's agitation or aggression. The care plan was only updated to include such interventions after the incident, indicating a lack of proactive measures to address known behavioral risks and ensure staff were adequately prepared to manage the resident's behaviors.