Failure to Provide Necessary Behavioral Health Services Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services as part of their comprehensive assessment, resulting in a physical altercation that caused harm to another resident. The resident in question was admitted with several medical diagnoses, including autoimmune thyroiditis, hyperlipidemia, gastroesophageal reflux disease, muscle weakness, and unsteadiness on feet. Despite being cognitively intact and not requiring mobility devices, the resident exhibited aggressive and unpredictable behavior, as documented in care plans and staff interviews. The care plan for verbal and physical aggression included referral to a psychologist or psychiatrist, but psychology notes indicated the resident repeatedly declined to be seen. Staff interviews revealed that the resident often became agitated, frustrated, and aggressive when things did not go their way, leading to concerns about potential harm to themselves and others. Nursing staff and supervisors described the resident as not getting along with roommates, yelling at staff, and requiring a 1:1 sitter for safety due to aggressive behavior. The need for a sitter was specifically to protect other residents and staff from potential physical altercations, as the resident was considered unpredictable and prone to anger. Despite these interventions, the facility allowed the resident to go out on pass without a sitter, with the DON stating that the facility's responsibility was limited to the resident's behavior inside the facility. The facility's policy on safety supervision emphasized individualized, resident-centered approaches based on assessed needs and identified hazards, but the implementation did not address the resident's behavioral health needs adequately, as evidenced by the incident and ongoing behavioral concerns.