Failure to Provide Adequate Behavioral Health Monitoring After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and competent staff to meet the behavioral health needs of residents, resulting in two physical altercations between two residents with significant psychiatric histories. One resident had diagnoses including schizophrenia, delusional disorder, and a history of social exclusion and rejection, with a PASRR indicating behaviors including physical aggression, poor impulse control, and triggers related to stealing. The other resident had schizoaffective disorder bipolar type, PTSD, anxiety, OCD, and schizophrenia, with a care plan noting a history of violence, impulsivity, lack of judgment, and triggers when feeling threatened. Both residents’ MDS assessments documented no behaviors, despite care plan information indicating behavioral risks. On the day of the incident, the two residents argued in the front hall outside one resident’s room, reportedly over money and the sale of items. During this first altercation, one resident punched the other in the head twice. Staff, including the ADON, intervened and separated them, with one resident returning to their room and the other walking toward their room on a separate, locked unit in the back hall. No staff were assigned to escort or monitor the resident returning to the back hall, and there was no documentation of behavioral intensive monitoring between the first and second incidents, despite the facility’s policy that residents requiring increased monitoring for behavioral or psychiatric issues should receive intensive or one-to-one monitoring with documentation in the medical record. A short time later, the residents encountered each other again near the nurse’s station. One resident confronted the other, reportedly grabbing the other’s shirt, and the same resident who initiated the earlier physical aggression punched the other resident in the face twice, causing the resident to fall to the floor, then kicked the resident in the head twice. Staff reported hearing a loud noise and then finding the resident on the floor by the nurse’s station. The injured resident experienced a bloody nose and loss of consciousness and was transported to the hospital for evaluation and treatment. Interviews with staff, including the CMT, ADON, DON, NP, and Assistant Administrator, confirmed that no staff escorted the resident back to the locked unit after the first altercation, that the door between the units did not always lock reliably, that residents from the back hall typically walked unescorted through the front hall to smoke, and that no one had been instructed to provide extra or intensive monitoring for either resident after the initial incident. These actions and inactions demonstrate the facility’s failure to implement its behavioral health and intensive monitoring policies to protect residents and address known behavioral health needs.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.