Failure to Provide Comprehensive Behavioral Health Care and Monitoring
Penalty
Summary
The facility failed to provide comprehensive behavioral health care and services for a resident with multiple diagnoses, including Parkinson's disease, dementia with behavioral disturbance, and anxiety. The resident experienced escalating behaviors such as yelling, hitting at staff, and agitation, which led to the administration of antipsychotic medication (Haldol) on two occasions. Despite these incidents, the resident's care plan was not updated to reflect the escalation of behaviors or the new interventions, and there was no documentation of monitoring for side effects following the administration of antipsychotic medication. Additionally, the facility did not ensure routine care was provided after the administration of Haldol. The resident, who required assistance with denture care, was not documented as having received oral or denture care on the night of or the morning after receiving the medication. This lapse was identified after the resident's partial denture went missing and was suspected to have been swallowed, leading to an emergency department visit. Interviews with staff confirmed that oral care should have been provided and documented, and that behavioral escalations should trigger updates to the care plan and increased monitoring. Record reviews and staff interviews further revealed that required behavioral monitoring, as ordered by the physician, was not consistently documented. The facility's policies required that new or exacerbated behaviors be reviewed and that care plans be updated with effective interventions, including medication reviews for side effects. However, these procedures were not followed in this case, resulting in a deficiency related to the provision of necessary behavioral health care and services.