Failure to Provide Behavioral Health Services and Medication Management
Penalty
Summary
The facility failed to provide appropriate treatment and behavioral health services to multiple residents with known mental health diagnoses and behavioral health histories. For three sampled residents, the facility did not implement required Preadmission Screening and Resident Review (PASRR) processes, failed to create or update care plans with necessary interventions for behaviors, and did not ensure the administration of prescribed psychotropic medications. One resident with a complex psychiatric history, including paranoid schizophrenia, anxiety disorder, and substance dependence, was admitted without the facility having the PASRR on file, and staff did not administer the resident's psychotropic medications as ordered. This resident exhibited escalating aggressive behaviors, including physical aggression toward staff and other residents, verbal outbursts, and attempts to elope, with no documented incident reports, care plan updates, or behavioral interventions during these episodes. Staff interviews revealed a lack of training and competency in managing behavioral health needs. Multiple staff members, including LPNs, CNAs, and housekeepers, reported not receiving education or in-service training on de-escalation techniques, behavioral health, or abuse and neglect prevention. Staff expressed feeling unprepared and unsafe when caring for residents with aggressive behaviors, and several reported that their concerns and requests for guidance from facility leadership were ignored. Documentation showed that staff were instructed not to document certain behavioral incidents, and there was a lack of behavior monitoring, incident reporting, and psychiatric follow-up for residents exhibiting significant behavioral symptoms. Other residents and staff reported feeling unsafe due to the aggressive behaviors of affected residents, with some residents stating they were traumatized or unable to sleep due to fear. Law enforcement was called multiple times to manage out-of-control behaviors, and police officers expressed concern about the facility's ability to manage residents with behavioral health needs. The facility's failure to provide required behavioral health services, medication management, and staff training resulted in an environment where both residents and staff were at risk, and appropriate care and oversight were not provided for residents with serious mental illness and behavioral challenges.