Failure to Provide Timely Behavioral Health and Pain Management Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan to support the behavioral health care needs of a resident with multiple psychiatric and physical diagnoses, including borderline personality disorder, PTSD, generalized anxiety disorder, severe morbid obesity, and chronic pain conditions. The resident had documented care plans addressing pain management, behavioral symptoms, aggressive behaviors, and psychiatric/mood issues, with specific interventions such as timely medication administration, emotional support, and strategies to minimize behavioral triggers. Despite these plans, the resident did not receive scheduled medications at the prescribed time after requesting them during the night, resulting in a delay of care. On the night in question, the resident requested her scheduled medications at 4:00 A.M., but the assigned RN was on break. Upon returning, the RN did not attempt to administer the medications or seek assistance from other available nurses, despite the presence of additional licensed staff on duty. The RN reported feeling unsafe due to the resident's agitated and hostile behavior, which included yelling and making derogatory remarks. Instead of following up with the physician or nurse practitioner regarding the late medication request, the RN only contacted facility management via text and did not receive a timely response. The resident ultimately did not receive her medications until several hours later, after experiencing significant pain. Interviews and documentation confirmed that other nurses could have administered the medications, and that the RN's failure to do so was not in accordance with facility policy or standard nursing practice. The facility's medication administration policy required medications to be given as ordered, and the behavioral assessment policy emphasized individualized interventions to address residents' needs. The incident was substantiated by medical record review, staff interviews, and disciplinary action taken against the RN for failing to provide necessary care.