Failure to Provide Effective Behavioral Health Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with multiple diagnoses, including non-Alzheimer's dementia, traumatic brain injury, anxiety disorder, depression, and psychotic disorder. The resident was cognitively intact but exhibited frequent verbal and physical behavioral symptoms directed at both staff and other residents. The care plan included interventions such as redirection, support to ignore provocations, and escalation to nursing or provider involvement if needed. However, staff interviews and incident reports revealed that these interventions were inconsistently implemented and often ineffective in managing the resident's behaviors. Multiple documented incidents occurred in which the resident engaged in verbally abusive and derogatory behavior toward other residents, leading to physical altercations. These included name-calling, threats, and provoking other residents, which resulted in several physical confrontations, some causing minor injuries such as abrasions and scratches. Staff consistently reported that their primary intervention was to tell the resident to stop, which was not reliably effective. In several cases, the resident's behavior escalated to the point where other residents retaliated physically, and staff were unable to de-escalate the situation or prevent harm. Interviews with CNAs and an RN indicated a lack of effective behavioral health interventions and uncertainty among staff regarding how to manage the resident's behaviors. Staff described the resident as persistently agitating others and noted that redirection and verbal prompts were insufficient. The repeated incidents and staff accounts demonstrate that the facility did not ensure the resident received the necessary behavioral health care and services to maintain the highest practicable physical, mental, and psychosocial well-being, resulting in actual harm.