Failure to Provide Timely Behavioral Health Intervention Resulting in Resident Injury
Penalty
Summary
The facility failed to provide necessary and appropriate behavioral health care and services to a resident experiencing a mental health crisis. The resident, who had a history of major depressive disorder, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, exhibited aggressive and erratic behavior, including attempts to elope and physical aggression. Despite these behaviors being reported by staff at the beginning of the shift, the response was limited to notifying the psychiatric nurse practitioner, who ordered a one-time dose of intramuscular Haldol and Benadryl. No order for hospital transfer was given at that time, and the resident's behavior continued to escalate. During the shift, the resident climbed onto a nightstand and broke a window with a metal object, subsequently falling and sustaining a severe injury to the right leg. Staff responded after hearing calls for help, and upon assessment, noted swelling and severe pain in the resident's right leg. Emergency services were called, and the resident was transferred to a general acute care hospital, where imaging confirmed acute, displaced fractures of the right tibia and fibula, requiring surgical intervention. The incident was witnessed by another resident, who reported feeling unsafe and disturbed by the aggressive behavior and was relieved when the resident was moved to another room. Interviews with staff revealed that the aggressive and elopement behaviors had been reported but not acted upon with sufficient urgency. The Director of Nursing acknowledged that the incident could have been avoided if the resident had been transferred for evaluation earlier, given the repeated attempts to elope and escalating aggression. The facility's policy required prompt investigation and documentation of such incidents, but the actions taken were not adequate to prevent harm to the resident and distress to others.