Failure to Provide Necessary Behavioral Health Services and Staff Training
Penalty
Summary
The facility failed to ensure that a resident with a history of aggressive behaviors received the necessary behavioral health care and services to maintain their highest practicable well-being. The resident, who had diagnoses including cognitive communication deficit, depression, and a history of physically abusive behavior, was involved in an incident where he attacked a CNA, resulting in a fall and injury. The care plan for the resident identified aggressive and abusive behaviors, but interventions were limited to psychosocial therapy, 1:1 oversight as needed, and general support for anxiety and depression, without specific strategies for staff to manage or de-escalate aggressive incidents. On the night of the incident, the resident became upset after a wound dressing was changed and additional staff entered his room, which he perceived as threatening. Despite the resident's request for a particular CNA to leave, the CNA remained and attempted to provide care, leading to a physical altercation. The resident reported feeling provoked and acted in self-defense, resulting in a struggle and subsequent fall. Staff interviews confirmed that the resident was known for aggressive behavior and had a prior negative interaction with the CNA involved in the incident. The facility did not provide staff with de-escalation or specialized training for managing aggressive behaviors prior to the incident. Staff received only general abuse and neglect training upon hire, and there were no documented interventions or training in place to address the specific behavioral health needs of residents exhibiting aggression. This lack of appropriate staff training and tailored interventions contributed to the escalation of the situation and the resulting injury.