Failure to Ensure Staff Competency in Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly those with complex psychiatric and behavioral conditions. Multiple staff members, including LPNs, CNAs, housekeepers, and medication technicians, reported not receiving training on behavioral management, de-escalation techniques, or abuse and neglect prevention. Staff expressed fear and a lack of confidence in their ability to safely care for residents exhibiting aggressive, violent, or self-harming behaviors. Interviews revealed that staff were not provided with guidance or interventions to manage residents with significant behavioral health needs, and some staff were assigned to one-on-one supervision without any relevant training or instructions. Several residents with serious mental illnesses, including schizophrenia, schizoaffective disorder, borderline personality disorder, and a history of substance abuse, exhibited frequent and severe behavioral disturbances. These included physical aggression toward staff and other residents, verbal outbursts, attempts to elope, destruction of property, and expressions of suicidal ideation. Documentation showed that these behaviors were ongoing and that staff and other residents felt unsafe. Despite these incidents, there was a lack of incident reporting, care plan updates, behavior monitoring, and documentation of nonpharmacological or pharmacological interventions in the residents' records. The facility's policies required annual in-service training for nurse aides, including behavioral health, and mandated that training be based on the special needs of the resident population. However, the report found that these policies were not implemented effectively, as evidenced by the lack of staff education and competency in managing behavioral health issues. The facility assessment identified a significant number of residents with behavioral health needs, but staff competencies did not align with these requirements. The absence of appropriate training and support led to repeated incidents where staff were unable to manage resident behaviors, resulting in harm to staff and residents, involvement of law enforcement, and ongoing distress within the facility.