Failure to Implement Behavioral Health Interventions and Care Planning for Resident with Repeated Unauthorized Absences
Penalty
Summary
The facility failed to develop and implement resident-centered care plan interventions and involve the interdisciplinary team (IDT) for a resident with a known history of leaving the facility without permission and failing to return from out on pass, as required by physician's orders. Despite repeated incidents where the resident left the facility without authorization, there was no evidence that behavioral interventions were initiated or that strategies were documented to address the resident's non-compliance and unsafe behaviors. The facility also did not document the resident's status upon return after these episodes, nor did they ensure timely notification of the physician regarding missed dialysis appointments and the resident's whereabouts. The resident in question had multiple complex medical diagnoses, including end stage renal disease requiring regular dialysis, diabetes, and dementia, but was assessed as cognitively intact and able to make decisions. The resident had physician orders specifying dialysis schedules and limitations on out-on-pass privileges, which required accompaniment by a family member and a maximum duration of four hours. However, the facility did not document the rationale for these restrictions, nor did they involve or communicate with the resident's family or emergency contacts as indicated in the orders. Additionally, a psychiatric evaluation was ordered but not initiated or scheduled, and there was no documentation explaining the reason for the psychiatric referral. Multiple progress notes and interviews revealed that the resident missed scheduled dialysis appointments after leaving the facility without permission, and the facility was often unaware of the resident's whereabouts until notified by external parties such as the dialysis center or police. The facility's own policy required behavioral health assessments, individualized interventions, and IDT involvement, but these steps were not documented or implemented. Staff interviews confirmed a lack of formal care planning, IDT review, or revision of privileges in response to the resident's repeated behaviors, and there was no evidence of family involvement in care planning as required.