F0740

D

Failure to Provide Adequate Behavioral Health Interventions and Monitoring

East Chicago, Indiana Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary behavioral health care and services to a resident with a history of significant psychiatric and behavioral issues. The resident’s diagnoses included schizophrenia, dementia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, alcohol abuse, and dysphagia. A quarterly MDS showed the resident was cognitively intact for daily decision-making but had worsening verbal behaviors. On one day, multiple behavior notes documented verbal aggression toward staff and residents, and the resident was placed on 30‑minute safety checks for 72 hours. Subsequently, the resident was sent to the hospital for evaluation and later returned to the facility.

Following the resident’s return, a physician ordered 15‑minute safety checks every shift with completion of a safety log, and nursing documentation indicated the resident was verbally aggressive and placed on 15‑minute checks before being sent again to a hospital behavioral health unit. However, the record lacked documentation of 15‑minute safety checks from late December through early February, despite ongoing behavior issues. During this period, multiple nurse’s notes documented repeated verbally aggressive behaviors on numerous dates. The behavior care plan, which identified aggression toward staff and residents related to mental illness, contained general interventions such as administering medications, assessing coping skills, and assessing understanding of the situation, but behavior interventions were not updated after the December incidents and hospitalizations.

On a later date in February, nurse’s notes documented verbal and physical aggression toward staff and another resident, leading to the resident being isolated from others and sent to the hospital for psychological evaluation. A facility‑reported incident described staff overhearing a verbal altercation between two residents, after which one resident was found on the floor with pain in the leg and hip and was sent to the hospital, while the aggressive resident was sent for psychiatric evaluation. A physician again ordered 15‑minute safety checks for 72 hours. The behavior care plan, originally dated in 2023 and revised in early February 2026, noted a history of verbal and physical aggression and included interventions such as praising progress, protecting the rights and safety of others, and placing the resident on 15‑minute safety checks, but the interventions had not been updated between September 2024 and mid‑February 2026 despite multiple aggressive incidents and hospitalizations. Interviews with the ADON, CNAs, and DON confirmed the resident’s unpredictable, unprovoked verbal and physical aggression, the lack of effective de‑escalation techniques, and that the resident was not on 15‑minute safety checks when returning from earlier psychological evaluations.