Failure to Address Psychosocial Needs and Prevent Harm from Hazardous Behaviors
Penalty
Summary
The facility failed to timely address the psychosocial needs and implement individualized interventions for a resident with a history of mental disorder, paranoia, hoarding behaviors, and a pattern of acquiring hazardous chemicals. The resident, who had diagnoses including schizophrenia with disorganized thoughts, anxiety, and paranoia, was noted to have intact cognition but poor decision-making skills. Despite being identified as requiring 24-hour supervision and having a care plan that included interventions for behaviors potentially causing harm to self or others, the resident continued to obtain and hoard facility chemicals over several months. Staff interviews and record reviews revealed that the resident's behaviors, including acquiring and mixing cleaning chemicals, were known to the staff and had been ongoing. On one occasion, staff found a spray bottle in the resident's room containing mixed chemicals, and on a prior day, other cleaning chemicals were also found and removed. The psychiatric nurse practitioner was unaware of the recent escalation in behaviors and hospitalizations, despite noting an increase in behaviors earlier in the year. The administrator confirmed that while the resident was educated about not having chemicals, there was no evidence that the interdisciplinary team addressed the increase in behaviors or implemented a psychosocial plan of care. The deficiency culminated when the resident was found with wet, blistered, and inflamed feet, which upon assessment were determined to be partial thickness burns. The resident was sent to the hospital and subsequently transferred to a burn center for treatment. The facility's policy required person-centered behavioral health care and regular review of care plans, especially when interventions were not effective or when there was a change in condition, but there was no documentation that these requirements were met in this case.