Failure to Provide Required Behavioral Health Interventions and Monitoring
Penalty
Summary
The facility failed to follow its policy and procedure on psychotherapeutic drug management for a resident diagnosed with major depressive disorder and paraplegia. The resident had a history of increased sadness and was prescribed Lexapro, with the dosage recently increased due to verbalized sadness. Despite this, staff did not provide non-pharmacological interventions as required by the care plan and facility policy when the resident expressed increased sadness. Documentation showed that on the day the resident verbalized increased sadness, no non-pharmacological interventions were provided or documented, even though the care plan and physician's order specified such interventions should be attempted prior to medication administration. Additionally, after the increase in Lexapro dosage, the resident was not monitored every shift for 72 hours as required by both the care plan and facility policy. Nursing notes and medication administration records revealed gaps in monitoring, with several shifts lacking documentation of the required checks for side effects, including suicidal ideation. Interviews with staff confirmed that the expected monitoring and documentation did not occur, and that staff relied on CNAs to report any unusual findings rather than conducting direct assessments as required. The failure to provide non-pharmacological interventions and to monitor the resident after a medication change resulted in the resident being found deceased in his room, with evidence of self-harm and no signs of life. The coroner determined the cause of death was neck compression. Staff interviews and record reviews confirmed that the required interventions and monitoring were not implemented or documented, directly leading to the deficiency cited in the report.