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:
Failure to identify resident-specific behavioral triggers: A resident with anxiety, depression, irritability, and trauma history was observed tearful and distressed while discussing multiple family losses and conflict with other residents and staff. Records showed psych notes about holiday-related distress, ruminating, accusations of poisoning, and mild paranoia, but the care plan did not include key triggers such as holidays/Thanksgiving, lab draws, grief, or paranoia, and did not list relaxation as an intervention.
PASRR care requirements were not incorporated into the care plans for two residents with serious mental illness and related behavioral health needs. One resident had repeated psychiatric hospitalizations after multiple psych med changes were made without the psychiatrist of record or guardian being consulted, while another resident’s PASRR services were omitted from the care plan, key meds were not consistently provided, and the resident was discharged without meds or coordinated supports before becoming homeless and later critically ill after an overdose.
Failure to Provide Behavioral Health Treatment and Psychotherapy: A resident with PTSD, depression, anxiety, and suicidal thoughts did not receive the consistent counseling/psychotherapy that was documented as needed, another resident with bipolar disorder and reported hallucinations was not reported to the PMHNP or referred for psychiatric consult, and a third resident with MDD, schizophrenia, dementia, GAD, and recurrent SI repeatedly sought psychiatric care but the record did not show follow-through with psychiatrist services or psychotherapy notes.
Failure to Document Ordered Behavior Monitoring: A resident with severely impaired cognition, anxiety disorder, and metabolic encephalopathy had a physician order to monitor agitation and inappropriate sexual behavior, including interventions and outcomes. Review of the chart identified multiple sexual and physical behavior incidents, but the MAR and behavior monitoring report lacked documentation for most of them, and the behavior report recorded no behaviors observed. An APRN and the ED confirmed the facility was responsible for completing the monitoring, but it was not done on the reviewed incidents.
A facility failed to individualize and consistently implement psychosocial and safety care plans for two residents with mental health or trauma histories. One resident with depression, anxiety, and PTSD had a recent suicide attempt and was supposed to have the room door left open and hazards addressed, but staff repeatedly closed the door and left other cords and items accessible. Another resident was placed on suicide precautions after a reported pill-related comment, but staff treated the intervention as standard rather than person-centered, gave plastic utensils despite the resident’s objections, and left crochet supplies in place while staff gave conflicting accounts of the resident’s safety needs.
A resident with dementia and severe cognitive impairment displayed repeated verbal and physical aggression toward her roommate, including blocking access, arguing, scratching, kicking, and threatening her, while requiring anti-anxiety meds and eventual psychiatric hospitalization. The roommate, who was cognitively intact, reported fear and distress, but the record showed no documented behavior pattern assessment, monitoring, or revision of the behavior care plan, and the two residents remained in the same room until the next day.
Failure to Identify Resident-Specific Behavioral Triggers
Penalty
Summary
The facility failed to ensure behavioral triggers were identified and assessed for a resident with diagnoses including left side weakness due to a stroke, anxiety disorder, insomnia, irritability and anger, major depressive disorder, and unspecified affective mood disorder. The resident’s annual BIMS score was 15, indicating no cognitive loss. During observation and interview, the resident was tearful while discussing the deaths of their mother and brother, stated they felt alone, described multiple family losses and the deaths of three friends at the facility, and reported conflict with two other residents who antagonized them and accused them of receiving preferential treatment. The resident also reported distrust of staff, alleged that the Dietary Manager shared protected health information with other residents, stated the facility arranged an outside agency evaluation without permission, and alleged a staff member intentionally struck them with another resident’s wheelchair. Record review showed psychiatric notes documenting concern about holidays and the upcoming anniversary of the brother’s death, ruminating on past events, accusations that staff attempted to poison the resident, and mild paranoia related to state examinations and dietary restrictions. The care plan identified trauma related to the deaths of the resident’s father, mother, and brother, and identified triggers such as other residents being assisted before them and the presence of a specific resident, but it did not include holidays, especially Thanksgiving, lab draws, paranoia, grief, or relaxation as an intervention. The Social Service Director stated the resident was paranoid at times and was aware the resident had been verbally abusive to a lab technician, but was not aware the resident blamed the hospital lab for their mother’s death.
PASRR Care Planning and Behavioral Health Services Not Incorporated
Penalty
Summary
The facility failed to incorporate PASRR-required treatment and service needs into the comprehensive care plans for two residents with serious mental illness and related behavioral health needs. One resident had diagnoses including non-Alzheimer’s dementia, traumatic brain injury, anxiety, bipolar disorder, and schizophrenia, and the Level II PASRR required ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP, individual therapy, occupational therapy, physical therapy, dental services, socialization and recreation, family involvement, and supportive counseling. Although the resident was admitted with multiple psychotropic medications and later experienced repeated psychiatric hospitalizations for aggressive behaviors, the PASRR directives were not addressed in the comprehensive care plan until months after admission. For that same resident, the facility sought psychiatric medication changes within 14 days of admission without conferring with the resident’s psychiatrist of record or the Court Appointed Guardian. The medication regimen was repeatedly changed, including haloperidol, buspirone, valproic acid, ziprasidone, lorazepam, and reductions in risperidone, while the resident continued to have escalating behavioral episodes and multiple transfers to emergency departments and inpatient psychiatric care. The record also showed the guardian did not consent to psychiatric medication management by anyone other than the resident’s psychiatrists at the VA psychiatric hospital, yet the facility’s psychiatric NP later documented that the resident would be removed from the NP’s service list. The second resident had a Level II PASRR for serious mental illness, with required services including ongoing psychiatric medication management, individual therapy, substance use evaluation and treatment access, supported community living planning, speech therapy, family involvement, supportive counseling, archived behavioral health records, and referral to recovery supports. The resident’s care plan did not include any of the PASRR-required interventions or even indicate that a Level II PASRR existed. The resident also had a lapse in tetrabenazine administration after admission, with the medication not given for several days and then discontinued after the facility reported cost and insurance issues, and the replacement medication was never administered because prior authorization was not completed. The second resident was discharged after requesting discharge, and the facility did not provide documentation that the Court Appointed Guardian had been revoked at the time of discharge. The resident left without medications, later used methamphetamine, became homeless after being removed from multiple temporary living arrangements, and was later hospitalized in critical condition in the ICU on a ventilator from a drug overdose. The facility administrator stated the resident was discharged within 2 hours of the request and there was not time to coordinate referrals for substance abuse counseling or support groups.
Failure to Provide Appropriate Behavioral Health Services
Penalty
Summary
The facility failed to ensure residents with diagnosed mental health disorders, psychosocial distress, and suicidal ideation received appropriate behavioral health treatment and services for three residents reviewed for behavioral-emotional health. The deficiencies involved failure to provide or obtain psychotherapy/counseling for one resident with PTSD, major depressive disorder, anxiety, and suicidal thoughts; failure to notify the PMHNP of another resident’s hallucinations; and failure to follow through with psychiatric referral/consultation for a third resident with multiple psychiatric diagnoses and repeated suicidal ideation. One resident was admitted with PTSD, major depressive disorder, and anxiety disorder. The record showed a psychotropic evaluation listing music and psychotherapy as non-pharmacologic care, and the care plan noted the resident had PTSD and had the potential to plan on ending his life because of pain and did not want to continue. Progress notes documented that the resident said he was struggling with pain and did not want to carry on, and staff wrote they would schedule a psych appointment so he could talk about depression and suicidal thoughts. During interview, the resident stated he was very depressed, did not want to go on, had accepted counseling, but no one ever showed up for the counseling sessions. He stated the Chaplain visited occasionally but was not qualified or useful for the help he needed, and he needed a psychiatric therapist trained in PTSD. The Chaplain stated he provided spiritual and emotional assistance, but did not have formal mental health training or formal training for treating PTSD. The NP stated she provided counseling only if the resident complained of issues, did not have consistent counseling sessions with the resident, and the record did not contain documentation that she provided counseling. Another resident was admitted with bipolar disorder. A progress note documented the resident reported moles in his room and under his covers, and CNA interview confirmed the resident had been seeing moles for a couple of months and that the nurse was told. The CNA stated housekeeping would go into the room, shake the sheets, and tell the resident the moles were gone. The NP stated she was not aware the resident saw moles and would have discussed medication changes with the provider if she had known. The record did not contain other psychotropic evaluations after an earlier evaluation, did not document hallucinations or delusions on the MDS, did not include hallucinations on the care plan, and did not contain referrals for a psychiatric consult. The third resident had diagnoses including major depressive disorder, paranoid schizophrenia, unspecified dementia, generalized anxiety disorder, and suicidal ideation. The record contained repeated crisis hotline calls, statements that the resident was depressed, wanted to die, or had been looking for an alternative to suicide, and multiple requests to see a psychiatrist or be transferred for psychiatric care. The resident also reported that the facility’s mental health treatment was not working and that he wanted to see an actual psychiatrist. Social services notes documented that the resident appeared to be hallucinating about God, was lonely, isolated, and not receiving the psychiatric care he needed. The provider notes showed plans to evaluate him by psychiatry or place referrals, but the medical record did not document that he was seen by a psychiatrist or that psychotherapy notes were present. The PMHNP stated she saw the resident only when issues arose or when nurses raised concerns, and the facility leadership confirmed the facility did not have a psychiatrist and that the resident wanted to see one.
Failure to Document Ordered Behavior Monitoring
Penalty
Summary
The facility failed to implement and accurately complete physician-ordered behavior monitoring for one resident with metabolic encephalopathy, other specified anxiety disorders, and severely impaired cognitive skills. The order, dated 11/17/2025, directed staff to monitor agitation and inappropriate sexual behavior, document interventions, chart to progress notes every shift, track the number of behavior episodes, and record whether outcomes were improved, worsened, or unchanged. Review of the resident’s record identified 14 incidents of sexual and/or physical behavior between 03/05/2026 and 05/05/2026. Record review showed the Medication Administration Record lacked documented evidence of behavior monitoring, interventions, and outcomes for 12 of the 14 incidents, and the Behavior Monitoring and Interventions Report lacked documented evidence for 13 of the 14 incidents. The Behavior Monitoring and Interventions Report also documented no behaviors observed. The APRN stated the facility was responsible for monitoring the resident and implementing interventions, and the ED confirmed behavior monitoring was not completed on the reviewed incident dates, although staff monitored the resident in other ways. The ED also stated behavior monitoring was intended to identify behavior triggers, trends, effectiveness of interventions, possible medication changes, and whether behaviors continued to occur.
Failure to Individualize Psychosocial and Safety Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans that addressed the emotional and psychosocial needs of two residents who had mental health histories and recent statements or behaviors related to self-harm. One resident was admitted with depression, anxiety, and PTSD, had a quarterly MDS showing cognitive intactness and depressed mood, and after being sent to the ED for altered mental status with an open bottle of OTC pain medicine and scattered tablets, returned to the facility on frequent checks with safety interventions. The care plan included keeping the room door propped open, removing hazardous objects, and shortening cords, but staff observations showed the door was repeatedly closed, the resident was left alone with access to other cords and items in the room, and multiple staff members were unaware of or inconsistent about the safety measures. The resident stated the door was supposed to remain open for safety, that staff kept closing it, and that the resident had not been talked to about other cords in the room. Staff interviews showed conflicting understanding of the intervention: some staff believed the door could be closed because the resident was not a fall risk, while others knew it was supposed to remain cracked open after the suicide attempt. The social services director and nursing staff acknowledged that the resident had access to other long cords, a plastic bag, and an exercise band, and that these items had not been addressed in the resident’s safety planning. The second resident had dementia and a trauma care plan calling for participation in decision-making. After a reported statement about taking a bunch of pills, the resident was placed on alert and frequent checks and the care plan was updated with suicide-risk interventions, including plastic utensils and removal of hazardous objects. However, staff later described the statement as a joke, and the resident said the interventions were not discussed with them and were not person-centered. The resident was observed receiving plastic silverware while still having access to crochet supplies and a crochet hook, and staff gave inconsistent accounts about whether the resident should have regular silverware or plastic utensils, whether the resident was informed, and whether other potentially hazardous items were considered.
Failure to address ongoing aggressive behaviors between roommates
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with behavioral and psychosocial needs by not implementing effective interventions to prevent or address ongoing physical and verbal behaviors. Resident 8 had severe cognitive impairment, dementia, and a behavior care plan that included identifying triggers, anticipating needs, monitoring danger to self and others, offering a stuffed animal when agitated, and using activities to assist with behaviors. Despite these interventions, records showed repeated incidents in which Resident 8 blocked access to the bathroom, argued with her roommate, became upset when the roommate was in the room, and later scratched the roommate’s face, left red marks, struck her with a baby doll, kicked her, and made threatening statements. Resident 8 required anti-anxiety medication on multiple occasions and was eventually sent to the hospital and involuntarily committed to a psychiatric unit for aggression and violent behaviors. Resident 68, who was cognitively intact and initially had no behaviors, was repeatedly affected by Resident 8’s actions and expressed fear of her roommate. A psychiatric provider note documented that Resident 68 reported Resident 8 hit her and got into her things, and after Resident 8 returned from the hospital, Resident 68 was shaking and stated she was scared to death with Resident 8 in the room. The record contained no documented evidence that Resident 8’s behaviors were assessed for patterns or precipitating factors, that staff monitored the behaviors, or that the behavior care plan was revised or new interventions were developed. The residents remained in the same room on the day Resident 8 returned, and they were not separated until the following day.
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