Failure to Assess and Respond to Resident’s Acute Mental Health Decline Leading to Harm
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, document, and address a resident’s mental health decline and behavioral changes, despite the resident’s significant psychiatric history and hospice status. The resident had diagnoses including bipolar disorder, schizoaffective disorder, major depressive disorder, epilepsy, COPD, and CKD, and was receiving hospice services. Antipsychotic medication (Abilify) had been gradually reduced from 10 mg to 5 mg on 11/11/25 and then to 2.5 mg on 12/11/25 as a gradual dose reduction. Psychology notes from 12/10/25 and 12/24/25 documented depression, low energy, poor concentration, and lack of motivation, but no psychosis, hallucinations, or suicidal ideation at those times. Behavior documentation from 12/07/25 through 01/02/26 showed no recorded behaviors, despite later staff reports of aggression and mood changes. On 12/22/25, nursing documentation noted low energy, inability to sleep, quiet and flat affect, and a behavior note described anhedonia and sadness. A PHQ-9 interview on 12/23/25 recorded no mood symptoms and indicated no need for a staff mood interview. On 12/24/25, psychology documented depressed affect, low energy, poor concentration, lack of interest, and sadness, but still no psychosis or suicidal ideation. On 12/30/25, a nursing progress note stated hospice was advised of increased aggression and that a PNP would adjust medications; however, there was no corresponding documentation of the resident’s aggression in the behavior charting, no record that the PNP actually saw the resident that day, and no evidence of any medication changes. A later interview with an RN clarified that the resident had been arguing with a roommate, refusing medications, and throwing things in his room, but these behaviors were not captured in the behavior documentation. During the night shift of 01/01/26–01/02/26, a CNA reported that the resident was “not right” and “actually scary,” lying in bed talking quietly to himself, shouting profanities when staff walked by, and becoming more agitated when approached, acting as if he would get out of bed. The CNA, who had cared for the resident for two to three years, stated this behavior was very out of character and reported her concerns to the LPN. The LPN attempted to give evening medications around 7:30 P.M., which the resident refused, and stated the door was kept open to observe him. The LPN later sent a text to the physician at 6:07 A.M. about the behaviors and lack of sleep but did not contact hospice as instructed by the DON and did not receive a response before leaving at 6:36 A.M. Behavior charting for 01/02/26 at 5:59 A.M. documented that the resident was verbally aggressive, yelling profanities, making threatening gestures, unapproachable, highly agitated, awake all night, and talking loudly with aggressive, profane language to himself; it also stated that the physician and on-call provider were notified, but there was no evidence of interventions implemented throughout the night. On the morning of 01/02/26, the DON reported receiving a call around 6:00 A.M. from the hall nurse about the resident talking to himself and to people who were not there and instructed the nurse to call hospice. The DON arrived at approximately 7:00 A.M., was told the resident was sleeping, and did not check on him. Hospice later confirmed the facility did not contact them about the change in mental status and that hospice only became aware when their nurse arrived for a routine visit and saw EMS assisting the resident. Around 7:50 A.M., a transportation driver arriving at the facility saw something in the snow and discovered the resident outside approximately 100 feet from his window, on his knees in the snow, agitated, stating he wanted to die, with abrasions, bright red skin, and wearing only light clothing. Facility staff and EMS reports indicated the resident was combative, aggressive, and psychotic, with altered mental status, injuries, and signs of hypothermia in temperatures around 21°F. EMS and hospital records documented that the resident was found kneeling in the snow with a cold wet blanket, with drag marks suggesting he had rolled down a hill from a first-floor window approximately 77 inches above the ground. The resident was pale with purple extremities, abrasions, and nonblanchable skin over heels and knees, and required soft restraints and sedative medication due to combative behavior. At the hospital, he was described as cold to the touch, with a core temperature of 95.6°F, delusions (including stating he was pregnant), and paranoia. He was admitted with hypothermia due to exposure, stage one frostbite to the heels, and delusions, and was placed on an Emergency Application for suspected suicide attempt after reportedly jumping from his window and remaining in the snow. Interviews with the PNP and hospice staff revealed discrepancies in Abilify dosing between hospice and facility records, lack of timely psychiatric reassessment after the GDR, and inconsistent or missing documentation of behavioral concerns. The facility’s Administrator and Vice President of Clinical Operations confirmed there was no facility policy related to meeting residents’ behavioral or psychological needs, and the facility’s change-in-condition policy required physician consultation for significant changes in mental or psychosocial status, which was not consistently followed in this case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who suffered a traumatic resident-to-resident assault with a head injury and intracranial bleeding continued to report fear that the other resident would enter her room again. The record showed the other resident had repeated room-entry and agitation issues, but there was no documentation of psychosocial monitoring for the affected resident after the incident, despite later anxiety and agitation noted in the chart.
A resident with TBI, stroke-related deficits, depression, and anxiety repeatedly displayed verbal aggression toward a former roommate, including threats, profanity, and blocking the other resident’s path in common areas. Although staff separated the residents at times and the resident was later sent to the ED for an aggressive reaction, the care plan did not identify the ongoing aggression toward the specific resident or include targeted interventions, and staff interviews showed inconsistent awareness and poor communication about the conflict.
Failure to Monitor and Document Behavioral Symptoms: A resident with dementia with agitation and Alzheimer’s disease had physician-ordered monitoring for agitated behaviors and non-pharmacological interventions, but staff did not consistently document his behaviors or interventions. The resident had a history of choking his wife, later misidentified and attempted to kiss a female resident, and entered another resident’s room where he allegedly kissed or attempted to kiss one resident and threatened the other. He was also observed unsupervised, walking the halls and interacting with other residents, and the DON confirmed the care plan and MD orders were not implemented for behavioral health management.
A resident with stroke, anxiety, and mild neurocognitive disorder with behavioral disturbance had escalating verbal aggression, threats, refusal of care, and statements suggesting paranoid or delusional thoughts. The care plan addressed verbal aggression, but the record showed worsening depression-related findings, repeated behavioral incidents, refusal of behavioral health services and other care, and recent self-mutilating behaviors. The DON acknowledged that a significant change PASARR probably should have been completed, while the SSD reported limited involvement beyond BIMS and PHQ screening.
Failure to provide appropriate behavioral health monitoring and services: two residents with significant psychiatric histories and behavioral care plans did not receive adequate oversight or timely provider notification. One resident assaulted a roommate, then was left with one-on-one monitoring that was not maintained within line of sight while the resident yelled, pounded on walls, and became increasingly agitated; another resident had repeated behavioral emergencies and aggression after an antipsychotic dose reduction, but staff did not adequately monitor the resident or promptly notify the psychiatric provider.
Delayed Psychiatric Services: A resident with neurocognitive disorder with Lewy bodies, psychosis, and anxiety had psych consult orders that were not completed in a timely manner. Staff reported the delay was related to obtaining consent from the wife, limited psych NP availability, vacation coverage gaps, and caseload prioritization, resulting in the resident not being seen by psych until well after the orders were placed.
Failure to Address Psychosocial Impact After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a resident who experienced a traumatic event received appropriate treatment and services after a resident-to-resident physical abuse incident that resulted in major injury. Resident #65, who was cognitively intact with a BIMS of 14, was found lying on the floor in the doorway to her room with bleeding from a head wound after Resident #42 was found in her room holding her iPad and a struggle occurred. Resident #65 was transferred to the ED, where trauma imaging showed an acute medial right frontal lobe multifocal subarachnoid hemorrhage with parafalcine and right tentorium subdural hematoma measuring up to 5 mm, with no midline shift. After the incident, Resident #65 reported ongoing fear that Resident #42 would enter her room again, stating staff took the other resident away when she came in and that she was afraid and had to watch her. The record showed Resident #42 had a pattern of entering other residents’ rooms, agitation, combativeness, and interpersonal conflict, with CPS recommending redirection, re-orientation, structured environment, and limited overstimulation. Resident #65’s notes documented denial of needs on one date and denial of psychosocial needs at a later social work visit, and no additional documentation of psychosocial monitoring was found. The resident later had increased anxiety with Buspar ordered and was verbally agitated with staff, while the care plan only addressed the subdural hemorrhage and monitoring for mental status changes and abnormal findings.
Failure to Address Ongoing Verbal Aggression Between Two Residents
Penalty
Summary
The facility failed to ensure that a resident with a traumatic brain injury, stroke-related deficits, depression, anxiety, and intermittent irritability received appropriate treatment and services to support mental and psychosocial well-being. The resident had a history of becoming verbally aggressive toward a former roommate, including threatening to beat the roommate and using profanity toward the roommate in common areas. The resident’s care plan identified general irritability, depression, anxiety, and the need to observe mood and notify the physician of changes, but it did not identify the resident’s repeated verbally aggressive behaviors toward the former roommate or include specific interventions to address those behaviors. After an initial incident in which the resident threatened the former roommate in the dining room, staff separated the residents for the rest of the day, but the care plan was not updated to reflect the behavior or targeted interventions. A later behavior management evaluation documented another episode in which the resident expressed an intent to harm the other resident, and staff notified the RN and the resident’s family. The resident was later sent to the emergency department after another confrontation involving the former roommate, where the resident had blocked the other resident’s path, used profanity, and was diagnosed with an aggressive reaction and given hydroxyzine. The resident continued to display verbally aggressive behavior toward the former roommate after these events, including cursing at the resident in the dayroom and refusing to move away when directed by staff. The care plan remained general and continued to describe irritability, staring triggers, limited abilities, poor safety awareness, and impulsivity, but still did not identify the ongoing aggression toward the former roommate or specific interventions for that behavior. Staff interviews reflected inconsistent awareness of the ongoing conflict, with some staff stating there were no further issues and others stating the problem was ongoing and communication between shifts was poor. The physician and family member both described the residents as not getting along, and the physician stated staff should monitor them like other residents, while the facility administrator stated she would not expect the care plan to contain specific interventions related to the other resident.
Failure to Monitor and Document Behavioral Symptoms
Penalty
Summary
The facility failed to implement physician-ordered monitoring and documentation of agitated behaviors and non-pharmacological interventions for a resident with dementia with agitation, Alzheimer’s disease, and a history of colon and prostate cancer. The resident’s MDS showed cognitive impairment, and a physician’s order dated February 18, 2026 directed staff to monitor and document agitated behaviors and attempted interventions every day and on every shift. The care plan also included interventions to engage the resident in structured activities and to observe, document, and report behavioral changes to the physician. Facility documentation showed that after the resident was admitted following an incident in which he choked his wife at home, he later misidentified a female resident as his wife, attempted to kiss her, and followed her until staff intervened, which led to his move to another floor. On July 16, 2026, he entered the room of two residents without invitation, allegedly kissed or attempted to kiss one resident without consent, and threatened the other resident with bodily harm when objected to. Review of documentation from June 27, 2026 through July 27, 2026 showed no evidence that his behavior was monitored and documented for 22 of 30 days, including July 16, 2026. During observation on July 27, 2026, he was seen unsupervised interacting with other residents, walking the halls independently, and sitting alone at a window, and the DON confirmed that the physician’s orders and care plan were not implemented for behavioral health management.
Failure to Provide Behavioral Health Services for Resident With Escalating Behavioral and Psychosocial Needs
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to a resident with diagnoses including stroke, generalized anxiety disorder, and mild neurocognitive disorder with behavioral disturbance, in order to assist him in achieving his highest practicable mental well-being. The facility policy required behavioral health care and medically-related social services based on comprehensive assessment and care planning, with behavior tracking and interdisciplinary assessment when behaviors or mood changes posed concerns. The resident’s care plan identified verbal aggression related to frustration with his family, with an intervention to monitor behavior episodes and determine underlying causes, but the record showed escalating behavioral concerns without documentation of a significant change PASARR assessment. The resident’s annual MDS documented little interest in doing anything and feeling down, depressed, or hopeless almost daily, along with rejection of care for one to three days out of seven and worsening behaviors since the prior assessment. Progress notes documented repeated verbal aggression, profanity, threats toward a visitor, and statements that staff were covering things up. He also made statements suggesting paranoid or delusional thoughts, including saying a nurse put something in his water and accusing staff of lying and drug use. The record also reflected refusal of medications, behavioral health services, insulin, and at times dialysis, along with recent documentation of self-mutilating behaviors. During interviews, the DON stated the resident had made other comments about dependent residents and had recent self-mutilating behaviors. The SSD stated she was not really involved in behavior management beyond BIMS and PHQ screening and described the resident as acting out more since returning from maternity leave. The Administrator stated the resident was aggressive, that the facility had tried counseling and family involvement, and that he had burned too many bridges. In a follow-up interview, the DON acknowledged that a significant change PASARR probably should have been completed and stated the staff were not documenting the delusions themselves, while also noting that the resident’s behaviors and self-mutilating behaviors had increased.
Failure to Provide Appropriate Behavioral Health Monitoring and Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents with mental disorders and behavioral health needs. One resident had diagnoses including bipolar disorder with psychotic features, schizoaffective disorder, depression, a history of substance abuse, prior suicide attempts, poor insight and judgment, impulsive behavior, and a care plan calling for close monitoring, coping skills, and notification of the physician for new behaviors. After a conflict with a roommate, the resident assaulted the roommate during a room move, causing the roommate to sustain an abrasion to the lip, scratches to the chest, and red marks around the neck. The resident was placed on one-on-one monitoring after the altercation, but staff were observed outside the room with the door closed while the resident yelled, pounded on the walls, and used profanity, and one assigned staff member was later found asleep on the floor outside the room. The same resident’s care plan and facility policies called for close behavioral monitoring, use of coping skills, de-escalation, and physician notification for behavioral changes. However, staff did not adequately monitor the resident when behaviors escalated, did not keep the resident within line of sight as required by the monitoring plan, and did not timely notify the psychiatric provider when the resident was yelling, hitting the walls, and displaying increased agitation. Interviews showed staff were unsure how far the behaviors had to go before calling a Code Green, and one staff member stated he or she opened the door only about every hour. The psychiatric provider stated staff should not have left the resident alone in the room with the door closed while the resident was yelling and hitting the wall. A second resident had a history of chronic mental illness, suicidal ideation, aggressive behavior, impaired judgment, impaired impulse control, and medication non-compliance. After a psychiatric medication reduction, the resident had several behavioral emergencies, aggressive behaviors, and an attempted assault on another resident, during which the resident injured an ankle and fell. The record showed the psychiatric provider expected close monitoring for recurrence of mood swings, irritability, insomnia, anxiety, psychosis, behavior changes, and safety concerns, but the facility did not adequately monitor the resident or timely notify the psychiatric provider when the resident continued to have behavioral emergencies and aggression.
Delayed Psychiatric Services
Penalty
Summary
The facility failed to ensure psychiatric services were provided timely and according to orders for one resident with neurocognitive disorder with Lewy bodies, psychosis, and anxiety. The resident’s quarterly MDS showed severely impaired cognition, dependence for all ADLs, and bowel and bladder incontinence. The medical record showed orders for psych services on 04/10/26 and again on 05/03/26, but the resident was not seen by psych until 06/28/26. The delay was discussed in interviews with facility staff. The DON stated the delay was related to obtaining consent from the wife and confirmed the psych consult orders. SSD stated verbal consent from the wife was not received until the care conference on 05/25/26 and was unsure why psych did not see the resident sooner after that. SSD also stated the psych NP only comes to the facility every two weeks and was on vacation with no coverage. The psych NP acknowledged awareness that the resident was not seen for approximately one month after consent to treat was received and stated new referrals are sometimes pushed back based on caseload.
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