Failure to Provide Individualized Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide individualized, medically-related social services and did not accurately or thoroughly assess a resident's mood, behavior, and psychosocial status. The resident in question exhibited mood symptoms, took an antidepressant, displayed anxiety, paranoia, frequently refused care, and acted out toward others. Despite these ongoing concerns, the facility did not ensure her care plan included specific, individualized interventions for staff to use when the resident displayed symptoms or concerns related to mood, behavior, or psychosocial issues. There was also no documentation of referrals for mental health services, even though such a need was identified by staff. Record reviews and staff interviews revealed inconsistencies and omissions in the resident's assessments and care planning. The psychosocial assessment contained errors, such as an impossible BIMS score, and failed to document interventions for care refusals or behavioral symptoms. Progress notes lacked consistent and individualized interventions, with some entries appearing to be repeated from previous notes. The care plan addressed issues like depression and paranoia but only included generic interventions such as monitoring medications or providing a lock box, without specific strategies for staff to address the resident's behaviors. No documentation was provided to show that mental health referrals were made prior to the end of the survey.