F0742

G

Failure to Provide Appropriate Behavioral Health Interventions for a Resident With Major Mental Illness

Richmond, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate, individualized behavioral health treatment and services to a resident with major mental illness, resulting in an altercation between a nurse and the resident. Resident B had multiple documented psychiatric and neurologic diagnoses, including bipolar disorder, anxiety, paranoid schizophrenia, dementia, insomnia, and Alzheimer’s disease. The resident’s care plans, initiated and updated on multiple dates, identified depression, anger, negative statements, withdrawal, a history of comments about not wanting to live, behavioral symptoms such as rejection of care, cursing at staff, wandering, hallucinations, and physical aggression toward staff, as well as social isolation and disturbed sleep patterns. The care plans contained specific non-pharmacological interventions such as allowing the resident time to express feelings, encouraging discussion of thoughts when sad or upset, speaking in a calm and unhurried voice, offering diversions, allowing a specific staff member to hold the resident’s hand, and leaving the resident alone when she was having behaviors so she could calm down.

On a documented change in condition, Resident B exhibited significant behavioral escalation, including paranoia, false accusations toward staff, disorientation to situation, yelling and screaming in her room and the hallway, waking other residents, threatening to beat up staff, cursing, and rolling around in her wheelchair staring at staff in an intimidating manner. The progress note, signed by RN 5, stated that staff and other residents did not provoke the resident and that staff only attempted to reorient her to reality and ask her to lower her voice. The resident was ultimately transferred to the hospital via EMS. However, interviews with multiple staff members later described that during a January night shift when the resident was yelling and screaming, RN 5 repeatedly tried to give the resident medication, told her to stop yelling and be respectful to other residents, and did not attempt other interventions consistent with the resident’s care plan.

The Unit Manager reported that she was unsure if RN 5 knew how to deal with residents with psychiatric issues and gave an example that RN 5 wanted to follow Resident B around when the resident needed to be left alone, despite being told not to do that. CNAs reported that during an episode of yelling and screaming, RN 5 would not leave the resident alone, was antagonizing her, and seemed spiteful, and that other staff had to remove the resident from RN 5. Another nurse (LPN 8) reported being told that RN 5 had attempted to get a CNA to place Resident B in involuntary seclusion in a supply closet because the resident was yelling and might wake other residents, and also observed that several residents appeared agitated with RN 5, who seemed to be making residents angry. RN 5 stated she did not understand why Resident B was on a regular unit and did not realize there were so many psychiatric residents with behaviors mixed with other residents. These observations and interviews, contrasted with the facility’s dementia and behavioral health policies requiring person-centered, non-pharmacological interventions and an environment conducive to mental and psychosocial well-being, support the finding that the facility failed to ensure Resident B received appropriate, individualized behavioral health services and that RN 5’s handling of interactions with the resident would likely cause psychological harm using the reasonable person concept.

The facility’s own policies on dementia and behavioral health services emphasized providing appropriate treatment and services to meet each resident’s highest practicable physical, mental, and psychosocial well-being, ensuring necessary behavioral health services, and implementing person-centered, non-pharmacological interventions. Despite these policies and the detailed care plans for Resident B, the documented and reported actions of RN 5—following the resident instead of leaving her alone, repeatedly pressing medication administration during an acute behavioral episode, verbally directing the resident to stop yelling and be respectful, allegedly attempting to have the resident placed in a supply closet, and generally antagonizing the resident—were inconsistent with the individualized interventions outlined in the care plan. Based on observation, interview, and record review, surveyors concluded that the facility failed to ensure that a resident with a major mental illness was treated appropriately and that individualized interventions were implemented, resulting in a physical/mental altercation between staff and the resident and likely psychological harm under the reasonable person concept.