F0742

D

Failure to Perform Root Cause Analysis and Person-Centered Behavioral Care Planning After Repeated Behavioral Emergencies

Moberly, Missouri Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide thorough, person-centered behavioral health assessment and care planning for a resident with serious mental illness and a history of behavioral issues, including wandering and assaultive behavior. The resident’s PASRR documented schizophrenia, psychosis, major depressive and mood disorders, substantial cognitive impairment, poor judgment and insight, wandering without knowing where he or she was, agitation, assaultive behaviors, and a need for a secured behavioral unit and structured environment. The PASRR also identified needs for psychiatric follow-up, behavioral monitoring, and interventions to change inappropriate behavior. Despite this, the resident’s care plan listed only general behavioral problems such as verbal aggression, agitation, mood swings, anxiety, and aggression, with broad non-pharmacological interventions and triggers, and did not incorporate all PASRR information or clearly defined, individualized coping strategies. Smoking, which staff later used as a primary de-escalation tool, was not listed as a coping skill.

On one date, the resident exhibited escalating behavior, yelling and using profane language toward staff, threatening another resident, and ultimately throwing a wet floor sign that struck a staff member in the face, causing injury and requiring EMS and police involvement. A behavioral emergency (Code Green) was called, and the resident was transported to a psychiatric hospital. Facility documentation, including the Registered Nurse Investigation and care plan entries, noted that an IDT meeting was “in progress” and referenced review of the PASRR and physician notification, but there was no documented interdisciplinary team meeting that analyzed the underlying causes of the behavior or revised the care plan with new, individualized interventions. The care plan problems related to physical aggression and staff injury were marked as “resolved” on the same day they were initiated and before the resident returned from the hospital, and the plan of care section that was supposed to list new interventions did not contain specific, updated approaches.

After the resident’s return, the facility failed to recognize and address new elopement-related behaviors through assessment and care plan revision. Shortly after being assessed as having no history of elopement, the resident left the secured unit, rapidly wheeled to the front entrance, and then into a family room where he or she broke a glass window with a hand in an attempt to leave the facility, sustaining lacerations that required 20 sutures and emergency room treatment. Staff interviews described the resident yelling about wanting to leave, bursting out of the secured unit when the door opened, and multiple staff being afraid of the resident. There was no documentation of an IDT meeting to determine root causes of this new elopement behavior or to develop person-centered interventions, and the care plan problem for the self-inflicted injury from breaking the window was also marked as resolved before the resident returned from a subsequent psychiatric hospitalization.

Following the resident’s second return from psychiatric hospitalization, the resident continued to have frequent behavioral emergencies, including verbal aggression, self-harm behavior involving reopening sutured wounds, and repeated attempts to leave the facility, resulting in five Code Greens over a 10‑day period. Observations showed the resident leaving the secured unit without staff, going to the front entrance, yelling and demanding to leave, and requiring behavioral emergency responses. Staff reported that the only effective redirection was allowing the resident to smoke, yet smoking was not incorporated into the care plan as a coping skill. The facility did not consistently notify the physician of these ongoing behaviors as required by policy, and the care plan revision dated after another front-door incident documented a new problem of unprovoked verbal aggression and attempts to leave but left the interventions section blank. Residents and staff reported being fearful of the resident’s erratic outbursts, and the record showed no documented root cause analysis or comprehensive, person-centered behavioral care planning to address the resident’s changing behavioral health and elopement-related needs.

The facility’s own policies on Behavioral Health Services, Behavioral Emergency, and Intensive Monitoring required person-centered assessment and care planning, IDT involvement, root cause analysis, close monitoring for residents with behavioral crises, and physician/psychiatrist notification after behavioral emergencies. Despite these policies, the record for this resident lacked evidence of thorough review of behavioral health emergencies, lacked documented IDT analysis of underlying causes, and failed to update and individualize the care plan with effective interventions in response to repeated behavioral crises, new elopement behavior, and ongoing aggression and distress.