Failure to Provide Necessary Care and Treatment for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with multiple mental health disorders, including schizoaffective disorder, psychosis, and depression, who exhibited behaviors such as threatening self-harm and harm to others. Documentation showed that the resident had episodes of screaming, cussing, and threatening to kill themself and others, as well as hearing voices and being aggressive toward staff. Despite these behaviors, there was no evidence that the resident was placed on behavior monitoring or received a psychiatric evaluation or medication reconciliation following these incidents. Nursing notes indicated that after a significant incident where the resident threatened self-harm and aggression, one-on-one monitoring was initiated and emergency services were contacted, but the resident was not transferred to the emergency room. Subsequent documentation revealed further aggressive behavior, including physically assaulting a nurse and another resident. Staff interviews confirmed that the resident was not on any special monitoring after re-admission and that no interventions for self-harm or aggression were in place. The care plan did not reflect the necessary interventions for the resident's mental health needs. Staff, including LPNs and the ADON, acknowledged that the resident should have received a higher level of care and that the facility environment was not equipped to manage such behaviors. There was no documentation of timely notification to psychiatric providers or adjustments to the resident's medication regimen after the incidents. The lack of appropriate assessment, monitoring, and intervention for the resident's mental health and behavioral issues led to the deficiency.
Removal Plan
- A review of all resident records was conducted to identify those with mental health disorders that may exhibit behaviors related to those disorders. All residents identified will have care plans updated to reflect mental health disorder/behavior. PCP and mental health will be aware of the identified residents to ensure all are evaluated and referred for services.
- All staff in-serviced that a current list of residents with mental health disorders is maintained at each nurse's desk.
- All staff in-serviced that when a resident displays that he/she is a harm to themselves or others and to report behavior immediately to nurse supervisor/administrator.
- Nursing staff will be in-serviced to notify the physician and mental health provider of the harmful behaviors immediately.
- The nursing staff will be in-serviced to request medication reconciliation with the physician and mental health provider following harmful/ mental health behaviors.
- Department supervisors are responsible for ensuring all in-services are completed.
- Employees who are unable to be reached will be required to in-service upon return to the facility.