Failure to Ensure Behavioral Health Training for Staff
Penalty
Summary
The facility failed to implement and maintain an effective behavioral health training program for all staff, as required by its own policies and facility assessment. Despite identifying 140 residents with behavioral health needs and 140 residents requiring long-term psychiatric management, documentation showed that several active employees, including a Certified Medication Technician, multiple CNAs, and an LPN, did not have completed behavioral health training. Additionally, one previous CNA involved in a resident incident had no documented behavioral health or CPI (Crisis Prevention Institute) training. Interviews with staff confirmed that some employees had not received specialized training since hire, were unsure how to respond to behavioral incidents, and did not understand facility codes related to behavioral emergencies. A specific incident involved a resident with a history of impulse disorder, paranoid schizophrenia, and obsessive-compulsive personality disorder, who was severely cognitively impaired. The resident had a care plan indicating a history of physical aggression and required staff to use de-escalation techniques and maintain personal space. During a behavioral crisis, a CNA without documented CPI training physically struck the resident multiple times after the resident pulled the CNA's hair. The altercation resulted in the resident sustaining a bloody nose and a bruise under the eye, and required intervention from other staff to separate the CNA from the resident. Record reviews and interviews revealed that the facility did not have an effective system to track behavioral health training prior to a certain date, and that some staff were allowed to work with residents or respond to behavioral emergencies without the required training. The facility's own policies required all staff, including non-nursing staff, to complete behavioral health and CPI training before working with residents, but this was not consistently enforced. The lack of training and documentation directly contributed to staff being unprepared to manage behavioral health crises, as evidenced by the incident involving the CNA and the resident.