Failure to Ensure Resident Safety, Psychosocial Well-being, and Person-Centered Care
Penalty
Summary
The facility failed to provide necessary care and services to promote quality of life and ensure the safety and psychosocial well-being of several residents. One resident experienced fear and developed PTSD after being assaulted by another resident with a history of escalating aggressive behaviors. Despite repeated incidents, the facility did not have an effective plan to monitor or manage the aggressive resident, resulting in further assaults and ongoing fear among other residents. Staff reported difficulty in preventing altercations and providing adequate supervision, and documentation showed that management continued to minimize the level of monitoring required. Another resident, with a history of elopement and significant medical and psychosocial needs, repeatedly expressed dissatisfaction with the facility and planned unsafe ways to leave. The resident experienced a significant sunburn after remaining outside for an extended period due to sadness over the loss of a friend, yet no staff member addressed the underlying emotional distress or implemented proactive interventions in the care plan. The facility did not conduct a root cause analysis or update the care plan to address triggers for the resident's behaviors, and staff were unaware of the resident's cognitive impairments and the need for closer monitoring until after a serious elopement incident occurred. A third resident, with dementia and major depressive disorder, made multiple verbalizations and attempts to leave the facility, including an actual elopement. Despite repeated expressions of distress and high elopement risk scores, the facility did not implement timely or person-centered interventions to ensure safety. There was a lack of documentation of psychosocial support, root cause analysis, or monitoring of the resident's mental health status, and the care plan did not reflect individualized interventions. The facility also failed to provide medically related social services, resulting in a deterioration of the resident's psychosocial well-being.