Failure to Provide Necessary Behavioral Health Services for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident with significant behavioral health diagnoses received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses including diabetes, hypertension, stroke, PTSD, major depressive disorder, and Cluster B personality disorder, exhibited repeated episodes of extreme agitation, verbal and physical aggression, and use of racial slurs and derogatory language towards a roommate and the roommate’s family members. These behaviors were documented on multiple occasions, including incidents of yelling, screaming, hitting, spitting, and making threatening or abusive remarks, particularly when the resident felt his personal space was encroached upon or when interacting with the roommate’s visitors. Despite the ongoing and escalating behavioral issues, the facility’s interventions were limited to offering room changes, which the resident refused, and implementing care plan interventions such as discussing behaviors with the resident, removing the resident from situations, and arranging for psychiatric and psychological consults as indicated. The care plan was updated to reflect the resident’s behavioral problems and included goals to reduce agitation, but the interventions did not effectively address or mitigate the resident’s aggressive and abusive behaviors. Staff interviews revealed that the resident’s behaviors were well-known, and there was reluctance to move the resident due to anticipated issues with other roommates. The roommate’s family expressed concerns for safety and documented their experiences in a letter to the facility, but the underlying behavioral health needs of the resident were not adequately addressed. The facility’s policy on behavior management required appropriate treatment for residents displaying mental disorders or psychosocial adjustment difficulties, including the use of non-pharmacological interventions before psychoactive medications. However, the documentation and interviews indicate that the facility did not ensure the resident received comprehensive behavioral health care and services as required, resulting in ongoing risk and negative psychosocial impact on the roommate, the roommate’s family, other residents, and staff.