Failure to Provide Behavioral Health Services After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident who was the victim of three separate incidents of resident-to-resident abuse. The resident, an elderly female with diagnoses including Alzheimer's disease, severe cognitive impairment, major depressive disorder, and chronic medical conditions, was assaulted on three occasions by another resident. Despite these incidents, there was no evidence that the resident received a psychology consultation or assessment following any of the assaults. Record reviews showed that the resident had a history of cognitive impairment and behavioral issues, such as intruding on others' privacy and taking personal items, but was not documented as having behavioral symptoms on her MDS. After each assault, interventions included 1:1 monitoring and trauma-informed screenings, which revealed positive responses indicating trauma. However, no referrals for psychological evaluation or therapy were made, even though the trauma screenings indicated the resident had experienced distress related to the assaults. Interviews with facility staff, including the social worker and DON, confirmed that no behavioral health referrals were initiated for the resident after the incidents. Staff cited the resident's advanced dementia and previous refusals of other services as reasons for not pursuing psychological services. The administrator stated that behavioral health services should be offered after such incidents, but this was not done. Family members reported the resident became more withdrawn after the abuse, but no behavioral health interventions were provided.