Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that a resident with bipolar disorder and dementia received necessary behavioral health care and services as required by their comprehensive assessment and care plan. The resident repeatedly refused prescribed psychotropic and dementia-related medications over an extended period, with documented refusals for multiple medications on numerous occasions. Despite these ongoing refusals, the facility did not assess, monitor, or implement appropriate behavioral health interventions, nor did they revise the resident's care plan to address the medication refusals. There was also a lack of timely initiation of psychological or psychiatric services in response to the refusals. The resident's behaviors escalated over time, including incidents of physical aggression towards staff and other residents, confusion, wandering, and taking other residents' belongings. Staff interviews revealed inconsistent practices regarding medication refusals, with some staff attempting multiple times to administer medications and others notifying physicians or family only after repeated refusals. Documentation showed that the resident's family was not informed about the consistent medication refusals, and the care plan did not include interventions to address these refusals or the resulting behavioral issues. The facility's interdisciplinary team did not effectively communicate or coordinate to address the resident's changing condition and behavioral health needs. As a result of these failures, the resident's behaviors escalated to the point of physical aggression towards another resident, leading to a transfer to an inpatient hospital for stabilization. The facility's lack of timely and appropriate response to the resident's medication refusals and behavioral health needs constituted a deficiency in providing necessary behavioral health care and services, as required by regulation.
Removal Plan
- All residents on dementia and psychotropic medications are reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse.
- The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication.
- All residents on psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions to address medication refusals and history of behaviors. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse.
- The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals. The medication administration report will also be reviewed during this process to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee. The care plan will be updated by the DON, ADON, or MDS Nurse.
- The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors.
- The medical director was notified of the immediate jeopardy citation by the administrator.
- An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal.
- The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors.