Failure to Provide Necessary Behavioral Health Services and Accurate Medication Administration
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with vascular dementia and behavioral disturbances. The resident was admitted with a history of violent and explosive behaviors, including physical aggression toward staff and other residents, paranoia, delusions, and non-compliance with care. Despite these documented behaviors, facility staff failed to accurately document the resident's behaviors, often recording 'no behaviors' on monitoring tools, even when there were reports of refusals, hitting, disrobing, and attempts to ambulate without assistance. Interviews with CNAs and LPNs confirmed the presence of aggressive and non-compliant behaviors, but these were not reflected in the official documentation or behavior monitoring records. The facility also failed to administer psychotropic medications as ordered and did not accurately document medication administration or refusals. Medication Administration Records (MARs) indicated that medications such as Rexulti, Olanzapine, Valproic Acid, Lexapro, and Mirtazapine were documented as administered, but pharmacy records and medication counts revealed discrepancies. For example, the supply of Rexulti and Olanzapine on hand did not match the number of doses documented as given, and staff interviews revealed that some medications were not available or not administered as ordered. Additionally, there was a lack of documentation regarding medication refusals, despite staff and CNA reports that the resident sometimes spit out or refused medications. The facility's policies required clear and accurate documentation of behaviors, medication administration, and refusals, as well as the development and regular review of a behavioral management plan. However, the interdisciplinary team did not ensure that the resident's behaviors were properly identified, documented, or addressed in the care plan. The lack of accurate documentation and failure to administer medications as ordered resulted in the resident not receiving necessary behavioral health care and services, as required by facility policy and regulatory standards.