Failure to Initiate Significant Change Assessment After Resident's Behavioral Decline
Penalty
Summary
The facility's Interdisciplinary Team (IDT) failed to initiate a Significant Change in Status Assessment (SCSA) for a resident who experienced a major decline in mental and behavioral health. The resident, admitted with multiple diagnoses including schizophrenia, psychosis, depression, and chronic pain, began refusing critical psychiatric medications such as aripiprazole and sertraline. This refusal persisted over several days, during which the resident exhibited escalating symptoms of psychosis, including delusions, hallucinations, paranoia, and severe behavioral disturbances. Despite these significant changes, there was no evidence in the clinical record of an IDT review or a determination to initiate an SCSA during this period. The resident's behavior became increasingly aggressive and erratic, with documented incidents of physical and verbal aggression towards other residents and staff, refusal to comply with facility rules, and multiple altercations. The resident was involved in several incidents, including slapping another resident, threatening staff, and starting fires within the facility. The crisis team and police were called multiple times, but no effective clinical interventions or comprehensive assessments were implemented by the facility. The resident's actions resulted in harm to other residents, such as bruising, and placed both residents and staff at risk. Throughout the period of behavioral escalation, the facility's records showed no evidence of an SCSA or other required assessments being completed after the resident's admission. Interviews with facility staff, including the DON and MDS RN, confirmed that no additional assessments were performed despite the resident's significant changes in condition. The facility's own policy required the IDT to assess and determine the cause of behavioral symptoms through the MDS/CAA process or team evaluation, but this was not documented or carried out in response to the resident's decline.