Failure to Provide Necessary Behavioral Health Services for Resident with Acute Behavioral Symptoms
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of psychoactive substance abuse, traumatic brain injury, and traumatic subarachnoid hemorrhage. The resident exhibited significant behavioral symptoms, including verbalized suicidal ideation, physical aggression, agitation, and wandering. Despite these acute behavioral changes, the facility did not utilize the on-call psychiatric service for evaluation or intervention on the day the behaviors escalated. Interviews and record reviews revealed that the resident was admitted for therapy following an accident and initially showed no behavioral issues. However, on the day in question, the resident became aggressive, was physically combative with staff, expressed suicidal thoughts, and disrupted other residents. Staff attempted to manage the behaviors through redirection and 1:1 supervision, but did not contact the on-call mental health provider, despite having access to this resource. The facility's own behavioral management policy outlined the use of such interventions, but these were not implemented. Multiple staff members, including the Administrator, DON, and nursing staff, confirmed that the on-call mental health service was not contacted. The mental health nurse practitioner and the resident's nurse practitioner both stated that the facility should have reached out for psychiatric support, which could have provided assessment, de-escalation, and medication management. The lack of timely referral to psychiatric services was identified as a failure to follow the resident's care plan and the facility's behavioral management policy.