Failure to Provide Necessary Behavioral Health Services and Address Repeated Policy Violations
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for multiple residents, specifically by not addressing ongoing behavioral issues such as repeated violations of drug and alcohol, out on pass, visiting, and contraband policies, as well as physical and verbal aggression toward other residents and staff. One resident with a history of opioid dependence and other psychoactive substance abuse was frequently observed leaving and returning to the facility at all hours, often without signing in or out, and sometimes refusing or missing prescribed medication doses. The resident also repeatedly brought unauthorized guests into the facility, including overnight stays, and was found with contraband items such as box cutters, utility blades, and lighters in their room. Staff interviews revealed that the resident would become hostile or threatening when confronted about these behaviors, leading staff to avoid entering the resident's room or addressing the issues directly. Despite the facility's policies requiring timely assessment, documentation, and intervention for adverse behavioral symptoms, there was a lack of consistent documentation and follow-up regarding the resident's behaviors and the presence of contraband. The care plan did not include interventions for the resident's repeated policy violations, such as bringing guests into the facility at inappropriate times, leaving the facility without proper notification, or bringing in potentially dangerous items. Staff reported uncertainty about their roles in monitoring for contraband and managing the resident's behaviors, with some believing that only housekeeping should check rooms, and others stating they were told not to confront the resident due to his aggressive demeanor. Interviews with staff, including LPNs, CNAs, and the Social Worker, indicated that administration was aware of the ongoing issues but did not provide clear guidance or effective interventions to address the resident's non-compliance and behavioral health needs. The Social Worker noted that the resident was not on a behavior contract and was often not present when psychiatric services were available. The DON and Administrator had removed contraband items from the resident's room on several occasions, but the resident continued to bring in more. Staff expressed concerns for their safety and the safety of other residents, as there were no clear instructions on how to manage the resident's aggressive or non-compliant behavior, especially when administration was not present.