Failure to Address and Report Escalating Behavioral Disturbances
Penalty
Summary
The facility failed to adequately address and manage the recurrent behavioral fluctuations of a resident with a history of bipolar disorder, delusional disorder, psychosis, and dementia, who was prescribed Depakote for mood stabilization. Despite physician orders and care plan directives to monitor and document episodes of behavioral disturbances, including verbally aggressive outbursts and diminished interest in activities of daily living (ADLs), the facility did not consistently notify the physician of escalating behaviors or document the effectiveness of non-pharmacological interventions (NPI). The resident experienced 11 incidents of behavioral disturbances within a short period, yet there was no evidence that the physician was informed or that the care plan interventions were fully implemented and evaluated as required. On one occasion, the resident physically struck another resident, resulting in the latter being hit on the left leg. Staff interviews confirmed that the aggressive behaviors were observed and that there was an expectation to notify the physician and document interventions, but this was not done. The medication administration records (MAR) and behavior monitoring logs indicated gaps in documentation, particularly regarding the use and effectiveness of NPIs prior to administering medication. Additionally, staff acknowledged that the physician should have been notified of the resident's increasing aggression to consider possible changes in medication or further evaluation. Facility policies and procedures required monitoring and reporting of behavioral symptoms and side effects of psychotropic medications, as well as collaboration with the physician and interdisciplinary team when changes in behavior occurred. However, these protocols were not followed, as evidenced by the lack of timely physician notification, incomplete documentation of behavioral episodes, and insufficient evaluation of interventions. This failure to adhere to established care processes contributed to an incident of resident-to-resident aggression and placed residents at risk for harm.