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 Address Behavioral and Psychosocial Needs: A resident with ESRD and a traumatic amputation had verbal outbursts, cursing, and derogatory language toward staff, but was not referred for behavioral health or grief counseling after his son’s death. The resident missed dialysis treatments because of behavior and a funeral conflict, and the NP, SSD, and DON confirmed there was no notification to the provider or referral to in-facility psychiatric services despite available behavioral health support.
Failure to assess and monitor suicidal ideation: A resident admitted with a painful hip fracture and no prior MH dx voiced that he would be better off dead on a PHQ-9 and later told therapy he would kill himself if he had the means. The SW documented the statements but did not notify admin, the DON, or the MD, and no MH referral or suicide precautions were implemented. Staff across disciplines were not informed of the prior suicidal comments, and the resident was later found unresponsive in bed with a cord around his neck; EMS determined the event was intentional self-harm and the death certificate listed suicide.
A resident with depression, cognitive decline, and severe cognitive impairment had an ordered psychology/psychiatry consult that was not completed for months despite ongoing agitation, refusal of care, yelling at staff, and other disruptive behaviors. The DON acknowledged the consult should have been arranged and completed, but the facility’s psych provider was on maternity leave and the covering provider did not appear, so no service was provided.
A resident made suicidal statements and later threatened to commit suicide, but the clinical record lacked evidence of a self-harm/suicide assessment or provider notification. The care plan was also not updated to include triggers, goals, or interventions for suicidal ideation, and facility leaders confirmed the gaps in the record.
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.
Failure to address depression and psychosocial needs: A resident with dementia, depressive disorder, and behavioral issues had PHQ-9 scores showing mild to moderate depression, but the record did not document follow-up for the increased score or consistent implementation of behavioral health recommendations. The resident often isolated in his room, declined activities, and had care plan interventions for depression and verbal aggression that were not consistently reflected in the chart or carried out as documented.
Failure to Address Behavioral and Psychosocial Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to address known psychosocial concerns for one resident who had verbal outbursts, cursed, and used derogatory language toward staff. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including end stage renal disease and a traumatic amputation of two or more right lesser toes. The Quarterly MDS identified verbal behavioral symptoms directed toward others, but the resident was not referred for in-facility psychiatric services or grief counseling despite the facility’s available behavioral health services. Record review and interviews showed that the resident missed dialysis treatments because of behavior and because one make-up dialysis appointment conflicted with his son’s funeral. The resident representative stated she was concerned about the missed medical and dialysis appointments and was not aware of any grief counseling offered after the death of the resident’s son. The DON confirmed that the resident missed dialysis because of behavior and that the resident also missed a dialysis appointment on the day of the funeral. She stated that the resident had shown a change in behavior during his stay and that staff received the brunt of his behavior. The NP stated she was not notified that the resident missed dialysis treatments and that there was no documentation that the covering NP was notified. The SSD confirmed awareness of the resident’s verbal outbursts but had not notified the primary healthcare provider and had not referred the resident to behavioral health services. The DON also confirmed that no referral was made to behavioral health contract services and that the resident’s doctor or NP was not notified that his behavior interfered with his scheduled dialysis treatments.
Failure to assess and monitor suicidal ideation
Penalty
Summary
The facility failed to ensure a resident who had voiced suicidal ideations received a mental health evaluation, monitoring, and suicide precautions after multiple staff members documented or heard statements that he would be better off dead or would kill himself if he had the means. The resident was admitted after a fall with a non-operable left hip fracture, acute pain, and moderate protein-calorie malnutrition, and he had no mental health diagnoses on admission. His baseline care plan did not include goals or interventions for depression or mental health. He also had a history of opioid and fentanyl exposure and a blood alcohol level of 15 at the hospital, and the Medical Director later documented a long-term depression history and alcohol use. On the resident’s depression screening, the Social Worker documented that the resident said he would be better off dead because of the amount of pain he was experiencing, and the PHQ-9 score was 10, indicating moderate depression. The Social Worker did not notify administration, the Medical Director, or nursing, did not begin monitoring, and did not make a mental health referral. Two days later, therapy staff documented that the resident stated he would kill himself if he had the means. Therapy staff reported the statement to the Therapy Manager and a nurse, but the information was not escalated to administration, the Medical Director, or other leadership at that time. The Medical Director later saw the resident and documented that he was miserable, upset, distraught, and in severe pain, but the depression was deferred until pain was controlled. The resident’s suicidal statements were not communicated consistently across disciplines, and staff interviews showed that multiple nurses and aides were unaware of the earlier suicidal comments. The Social Worker later met with the resident after administration learned of the statement and reported that he was no longer suicidal, but no formal assessment or psychiatric referral was completed. On the evening of the incident, the resident was described as irritated and wanting to be left alone; he also asked for his phone to be unplugged and did not want to talk with family. Later that night, he was found unresponsive in bed with the bed control cord wrapped tightly around his neck, without breathing or a pulse. EMS determined the cardiac arrest was associated with intentional self-harm by hanging, and the death certificate listed the manner of death as suicide by self-strangulation with the bed control cord.
Delayed Psychology/Psychiatry Consult for Resident With Behavioral Symptoms
Penalty
Summary
The facility failed to ensure timely completion of a physician-ordered psychology/psychiatry consult for one resident with depression, age-related cognitive decline, and cognitive communication deficit. The resident’s MDS dated 2/25/26 indicated severe cognitive impairment and problematic behaviors directed toward others, including threatening, yelling at, or cursing at staff. An order dated 7/30/25 for a psychology/psychiatry consult with follow-up treatment as indicated was present in the order summary, but there was no evidence the consult was completed during the 11-month period reviewed. Facility progress notes documented ongoing behavioral and psychological concerns during that period, including increased evening agitation, multiple outbursts toward staff, fear of staff leaving the room, refusal of care, yelling and waving her hand aggressively at staff, calling police to complain that she was being held captive, and another episode of yelling during care. During interview, the resident stated one incident reported as abuse occurred because a CNA was rushing her. The DON stated the consult should have been arranged and completed and explained that the facility’s psychology/psychiatry provider had been on maternity leave and the covering provider failed to show up, resulting in no service being provided.
Failure to Assess and Care Plan Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed suicidal ideation and signs of self-harm. The resident’s care plan meeting note dated 4/30/26 documented that the resident said he/she might as well commit suicide, but the clinical record lacked evidence that the resident was assessed for self-harm or suicide ideation, and there was no evidence that the provider was notified of the statement. A later provider communication note dated 5/10/26 documented increasing confusion and a threat to commit suicide that night. The resident’s most recent care plan update on 5/12/26 did not include goals or interventions related to suicidal ideation. During interviews on 6/2/26 and 6/3/26, the Market Clinical Lead, Social Service Director, Market Clinical Advisor, DON, and Market Clinical Lead confirmed there was no evidence the doctor had been notified, no evidence the resident had been assessed for self-harm/suicidal ideation, and no evidence the care plan had been updated to include triggers, goals, or interventions for threat of self-harm or suicide ideation.
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.
Failure to Address Depression and Psychosocial Needs
Penalty
Summary
The facility failed to ensure a resident with diagnoses including dementia with behavioral disturbance and depressive disorder received appropriate treatment and services to support mental and psychosocial well-being. The resident’s MDS showed moderate cognitive impairment, verbal behaviors toward others, and depression identified through PHQ-9 screening. The resident also received an antidepressant and an antipsychotic medication, and the record showed no gradual dose reduction attempt or documentation that it was clinically contraindicated. Record review and observations showed the resident spent much of the day in his room with the lights off and blinds closed, often sat alone in the dining room, and told staff he did not like to participate in facility activities. The care plan identified depression, self-isolation, verbal aggression, and the need for psychosocial monitoring, emotional support, activities of interest, and behavioral interventions such as calm approach, positive reassurance, one-on-one interactions, and a quiet environment. A psychiatry note also recommended a more proactive approach to encouraging the resident to attend activities, such as telling him it was time to go rather than asking if he wanted to go, but this recommendation was not reflected in the electronic record. The resident’s PHQ-9 scores showed mild depression in September 2025, then moderate depression in December 2025 and again in March 2026, but the record did not show documentation addressing the increased score, follow-up, interventions, or services offered. Physician orders included monitoring for behaviors, isolation, side effects of psychotropic medications, and offering non-pharmacological interventions, but the record showed these interventions were not consistently implemented or documented as effective. Staff interviews confirmed the resident could become upset when approached in a way that suggested he was blamed for resident-to-resident altercations, and the administrator and social services director acknowledged they could not locate documentation showing why the PHQ-9 score increased or that the behavioral health recommendation had been incorporated into the care plan.
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