Failure to Notify Provider of Resident's Escalating Behaviors and Suicidal Statements
Penalty
Summary
The facility failed to notify a resident's provider of new or escalating behaviors, as required by policy. The resident in question had a history of vascular dementia, cognitive communication deficit, major depressive disorder, and anxiety disorder, and was admitted to the facility before being transferred to the hospital. The resident exhibited significant behavioral symptoms, including aggression, wandering, restlessness, physical aggression towards staff and other residents, suicidal and death statements, and increased agitation, particularly following the discontinuation of certain medications. Despite these behaviors being documented in the electronic medical record (EMR), there was no evidence that the provider was notified of these incidents over multiple periods. The care plan for the resident lacked individualized interventions related to the resident's specific behaviors and triggers. Multiple behavior notes documented incidents such as aggression, attempts to strike or bite staff, suicidal ideation, and increased fall risk. These behaviors were observed and recorded by staff, but the medical record did not show that the provider was informed of these significant changes or incidents, including after medication changes that appeared to exacerbate the resident's symptoms. Interviews with nursing staff confirmed that provider notification was expected in such cases, but documentation of such notifications was absent during critical periods. The facility's policy required immediate notification of the resident, physician, and representative when there was a significant change in the resident's physical, mental, or psychosocial status. However, the provider was not notified of the resident's escalating behaviors, suicidal statements, or increased agitation and aggression, particularly after medication adjustments. This lack of timely communication with the provider persisted until the resident's condition deteriorated to the point of requiring emergency intervention and hospital transfer.