Failure to Provide Behavioral Health Services and Substance Use Care Planning Resulting in Resident Overdoses
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including assessment and care planning, for three residents with known substance use disorders, as required by facility policy and PASRR recommendations. The facility’s Illicit Drug and Alcohol policy and Behavioral Health Services policy required that residents with substance use disorders receive person-centered behavioral health assessments, care plans, and interventions, including care plans addressing illicit drug, marijuana, or alcohol use, increased monitoring when substance use was suspected, and access to substance abuse programming and supports. For Resident #3, the PASRR documented serious mental illness, polysubstance dependence, recent methamphetamine use, and recommendations for substance abuse programming such as community-based treatment, 12-step programs, and residential/intensive treatment. Despite this, the medical record contained no risk assessments related to substance use/abuse, no documentation of substance abuse programming or NA/AA resources, and no care plan problem, goal, or interventions addressing illicit substance use or the PASRR recommendations. The facility also failed to clearly define, document, and implement restrictions and monitoring measures it imposed on Resident #3 after repeated findings of drug paraphernalia. Progress notes documented that Resident #3 was found with illicit drug paraphernalia and was placed on a 30‑day restriction, later on supervised visitation and LOA restriction, and then on a 60‑day restriction with a 30‑day discharge notice. However, there was no documentation describing what these restrictions entailed, no clear staff instructions or education on how to implement them, and no assessment of the resident’s substance use needs or resources. The care plan referenced behavior problems with possession of illegal substances, restriction, re‑education on policy, and LOA restriction, but did not specify staff interventions for LOA or supervised visitation. Facility sign‑in/sign‑out sheets for multiple dates showed no records of visitor logs or resident sign‑outs, even though staff and administration stated that Resident #3 was supposed to have someone sign him/her out and show ID when leaving the building. For Residents #1 and #2, both had documented histories of substance use disorders and serious mental illness in their PASRRs, including alcohol dependence, cocaine dependence, polysubstance abuse, and a need for 24‑hour supervision and structured oversight to prevent relapse. Resident #1’s PASRR and admission information reflected alcohol dependence, chronic psychiatric conditions, and the need for around‑the‑clock nursing care, while Resident #2’s PASRR documented recent substance use, polysubstance abuse, and a requirement for continuous protective oversight. Despite these histories, neither resident had risk assessments related to substance use/abuse, and their care plans lacked any focus, goals, or interventions addressing alcohol or other substance dependence. There was also no documentation of NA/AA resources, education, or attendance for either resident. These failures in assessment, care planning, and implementation of behavioral health and substance use interventions preceded an incident in which Resident #3, who had a known history of polysubstance abuse and was on restriction, obtained fentanyl and used it in his/her room. According to the facility’s Suspected Abuse Investigation and nursing notes, on the evening in question Resident #3 was actively using a substance in his/her room when Residents #1 and #2 entered. Resident #3 told them to take a hit of the illicit substance, Resident #2 held the foil, and both Residents #1 and #2 used the substance and then became unconscious. Resident #3 later went to the nurses’ station requesting Narcan, and staff found one resident unresponsive in a wheelchair and the other unresponsive on the floor, both with pulses but not responding. LPNs administered Narcan to both residents, who responded after second doses, and EMS transported them to the hospital. Hospital records for Resident #1 documented an admission for overdose, with a history that he/she had been smoking fentanyl with another resident, accidentally overdosed, and was found unresponsive, and that he/she had never used fentanyl before but wanted to experience the high. Hospital records for Resident #2 documented an admission for pulmonary edema and drug overdose, with a history of polysubstance abuse and current use of liquor, cocaine, methamphetamines, and fentanyl, and that he/she reported planning to smoke methamphetamines with a friend but instead was given fentanyl and overdosed. Interviews with Residents #1 and #2 confirmed that they smoked what they believed to be methamphetamine with Resident #3, later learned it was fentanyl, and lost consciousness. Interviews with staff and residents also confirmed that Resident #3 had been on restriction due to prior paraphernalia findings, that staff did not search residents on return from LOA, that sign‑out procedures were not consistently documented, and that there was no special monitoring beyond the expectation that someone sign the resident out, which was not reflected in the facility’s sign‑in/sign‑out records.
Penalty
Resources
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Failure to provide ordered psychology services for a resident with depression and anxiety. The resident’s record showed an order for psych eval and treatment, but there was no documentation of recent psych visits despite a note stating she saw psychology regularly. The resident reported frequent sadness, crying, thoughts about dying, and wanting to talk to a counselor. The SSD said she received the order but did not send the referral, and the DON said social services was responsible for processing psychology orders.
A resident with bipolar disorder, anxiety, and intellectual disability had persistent escalating behaviors including yelling, cursing, throwing objects, physical aggression, self-injury, threats, and sexually inappropriate actions. Despite repeated BH evaluations, 1:1 supervision, and a psychiatric hospitalization, the care plan interventions were not shown to be evaluated or revised in response to the ongoing behaviors, and the NHA could not provide evidence that the interdisciplinary team had reviewed their effectiveness.
A resident with schizoaffective disorder, MDD, and bipolar disorder became frustrated during medication pass when the routine was delayed and different from usual. The resident became verbally aggressive and charged toward the med room, but staff did not call Code Green when escalation began. A CMT then used a non-approved CPI technique by grabbing the resident by the collar and taking the resident to the ground, resulting in minor facial abrasions and complaints of ankle and toe pain.
Failure to provide behavioral health services for a resident with schizophrenia and moderate cognitive impairment. The resident was receiving multiple antipsychotic meds and had a care plan for agitation, anger, cursing, grabbing, hitting, and kicking. The resident struck another resident, sending both to the ED. A PASRR Level II review recommended case management and a neurocognitive eval, but the record showed no evidence these services were provided.
A resident with schizoaffective disorder, anxiety, severe cognitive impairment, and ongoing behavioral issues was not evaluated or treated by psych care despite a physician order for psych services. Staff observed refusals of care, pushing away the CNA, throwing items, and attempting to pull at his catheter, while the CNA said a snack was the easiest way to get him to cooperate. The psych PA said he never assessed the resident because of an issue with the order, and facility staff reported the referral process was sent but the resident still was not seen.
A resident with dementia, bipolar disorder, and schizophrenia repeatedly refused antipsychotic meds, including oral fluphenazine and later fluphenazine decanoate. Staff documented medication nonadherence, catatonic features such as withdrawal, intermittent mutism, and posturing, plus poor PO intake, weight loss, and UTI. The resident was later transferred to the hospital for altered mental status and agitation after the next of kin called 911.
Failure to Provide Ordered Psychology Services
Penalty
Summary
The facility failed to provide ordered behavioral health services for one resident with depression and anxiety. The resident’s MDS indicated she was cognitively intact, had no hallucinations or delusions, and was depressed with trouble falling asleep and poor appetite. Her medical record included an order for escitalopram for depression and a care plan directing staff to arrange psychology follow-up as indicated, discuss concerns and fears with the resident, and provide time and encouragement for her to express feelings. The resident’s care conference note stated she was cognitively intact, had mild signs and symptoms of depression, had no behaviors, and saw psychology on a regular basis. The resident’s EMR contained an order for psychology to evaluate and treat, but there was no documentation of psychology visits in the last 12 months, which conflicted with the social services note. During observation and interview, the resident stated she became sad very often, cried and could not stop crying, thought about dying, and wanted to talk to somebody or a counselor. The DON stated social services oversaw psychology orders, and the SSD stated the resident had previously received psychology services but was discharged in December 2024. The SSD also stated she received the psychology order but did not send the referral, and later stated she needed to obtain a new consent and send the referral because she was unaware the facility had in-house psychology visits.
Failure to Evaluate and Revise Behavioral Health Interventions
Penalty
Summary
The facility failed to implement, evaluate, and revise behavioral health interventions for a resident with bipolar disorder, anxiety, and intellectual disability who had a persistent and escalating pattern of behavioral symptoms. The resident’s annual MDS dated May 4, 2026, showed he was cognitively intact with a BIMS score of 15. The facility policy required behavioral health services as needed to support residents’ highest practicable physical, mental, and psychosocial well-being, with staff promoting dignity, autonomy, privacy, socialization, and safety. Clinical documentation showed repeated episodes of yelling, screaming, cursing, verbal aggression, physical aggression, throwing objects, destruction of property, threats toward staff, self-injurious behaviors, sexualized behaviors, refusal of care, and behaviors that disrupted other residents. The resident pulled a needle from his arm during a blood draw, spit at and cursed a phlebotomist, threw belongings into the hallway, became combative with care, threatened staff, threw utensils and other items, ripped equipment from the wall, and caused other residents to report fear of him. He also struck another resident in the leg with a highlighter, threatened to kill a nurse, distributed sexually inappropriate notes, threatened to kill staff, and required one-to-one observation and a 302 psychiatric commitment with hospital transfer after escalating aggression and self-harm statements. After returning from the hospital, the resident continued to display frequent and escalating behaviors despite the existing care plan interventions. Documentation showed ongoing yelling, cursing, throwing objects, spitting medications, striking himself, threatening staff, refusing care, and repeated need for behavioral health involvement and one-to-one supervision. The care plan identified risks related to self-harm, physical abuse, inappropriate sexual behavior, and rejection of care, and directed staff to allow self-soothing, monitor triggers, reapproach after agitation, and discourage throwing objects into the hallway. However, the record did not show that the interdisciplinary team evaluated whether those interventions were effective or revised the care plan in response to the resident’s changing behavioral needs. During interview, the NHA was unable to provide evidence that the team had evaluated the interventions or revised the behavioral care plan despite the persistent pattern of escalating behaviors.
Failure to Follow CPI During Resident Behavioral Escalation
Penalty
Summary
The facility failed to follow its CPI policy and behavioral health expectations for a resident with a history of aggression toward staff. The resident had diagnoses including schizoaffective disorder, major depressive disorder, and bipolar disorder, and the MDS showed the resident was cognitively intact but had physical behavioral symptoms directed toward others. The care plan identified negative behaviors such as charging people, seeking revenge, hitting, and tackling, and listed triggers including bullying, stealing, and loss of control. During morning medication administration, the resident became frustrated because the medication pass was slower than usual and different from the resident’s normal routine. The resident repeatedly demanded medications, became verbally aggressive, and approached the medication room doorway. Staff did not initiate a Code Green when the resident began escalating. Instead, the CMT told the resident he/she would document the medications as refused, which further upset the resident. The resident then yelled and charged at the medication room door. When the resident entered the medication room area and the situation escalated, the CMT used a non-approved technique by grabbing the resident by the collar and moving the resident to the ground. The resident sustained an abrasion to the right cheek and right eyebrow and complained of pain to the right ankle and big right toe. Witness statements and staff interviews described that the response did not follow approved CPI techniques and that Code Green procedures were not initiated early in the escalation.
Failure to Provide Behavioral Health Services for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure behavioral health services were provided to a resident with schizophrenia and moderate cognitive impairment, as shown by a BIMS score of 10 out of 15. The resident’s MAR showed treatment with multiple antipsychotic medications, including haloperidol, clozapine, and aripiprazole. The care plan identified impaired psychosocial well-being with behaviors requiring intervention, including agitation, anger, cursing, grabbing, hitting, and kicking, and listed interventions such as redirection, removal from the situation, meaningful activity, reapproach, and one-to-one supervision. A facility incident report showed the resident struck another resident on the left side of the face, and both residents were assessed and sent to the ED. The resident’s PASRR Level II review recommended case management and a neurocognitive evaluation, but the medical record showed no evidence that either a neurocognitive evaluation or mental health services were provided. A social services assistant stated that she and another assistant checked on the resident a couple of times a day, especially when the resident had behaviors, and confirmed the resident had not received a neurocognitive evaluation upon admission and did not receive case management services.
Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident with diagnoses including schizoaffective disorder, bipolar type, generalized anxiety disorder, restless and agitation, and a healing spinal compression fracture. The resident’s quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment, and documented verbal behavioral symptoms toward others and refusals of care. His care plan identified behavior problems such as throwing his foley bag, oxygen tubing, call light, and blankets on the floor, as well as resistance to care including refusing lab draws, medications, and showers at times. The resident also had a physician order for psych care to evaluate and treat related to schizoaffective disorder, bipolar type. During observation, he was awake and alert in his room and later resisted hands-on care, saying no, pushing the CNA’s hand away, throwing his call light, and attempting to pull on his indwelling catheter. The CNA stated these behaviors were typical and that a snack was the easiest way to get him to cooperate. Nursing staff were aware of his behaviors, and the resident was not receiving psychosocial services from the psych care team at the time of the survey. The psychological services PA stated he had never assessed the resident and had been unable to see him because of an unknown problem with the order. Facility staff reported that a referral had been sent and corrected orders were later provided, but the resident still had not been seen. The LVN stated the referral was written and sent through the system, after which nursing staff had no further role, while the Regional Compliance Nurse stated staff should notify the psych PA and that residents exhibiting behaviors should be seen. The facility policy stated residents would receive behavioral health services as needed to attain or maintain the highest practical physical, mental, and psychosocial well-being.
Failure to Provide Behavioral Health Care for a Resident With Medication Refusal and Catatonic Symptoms
Penalty
Summary
The facility failed to ensure a resident received necessary behavioral health care and services in accordance with the comprehensive assessment and plan of care. The resident had diagnoses including non-Alzheimer's dementia, bipolar disorder, and schizophrenia, and the annual assessment documented moderate cognitive impairment, loneliness or isolation at times, and routine antipsychotic use. The psychoactive medication care plan identified the resident as being at risk for side effects related to psychoactive medications and directed staff to administer medications as ordered, monitor behaviors and response to medications, and notify the physician if medications were refused. The resident repeatedly refused antipsychotic medication, including oral fluphenazine and later fluphenazine decanoate injections, with the medication administration records showing 144 refusals out of 178 doses from March through June. Psychiatric and medical notes documented medication nonadherence and catatonic features such as withdrawal, intermittent mutism, and posturing, along with decreased oral intake and impaired functioning from baseline. Nursing and provider notes also documented ongoing refusals of all medications, and the physician and nurse practitioner were made aware of the refusals on multiple occasions. The resident’s condition continued to decline, with documentation of urinary tract infection, poor oral intake, and weight loss, and the resident was transferred to the hospital after the next of kin called 911 for further evaluation. Hospital discharge paperwork documented admission for altered mental status, agitation, urinary tract infection, poor oral intake, and reported weight loss. The psychiatrist stated that holding the antipsychotic medication may have contributed to catatonia and that if they had known the injectable antipsychotic was not being taken regularly, the resident would have been sent to the hospital within a month to stabilize medication; the psychiatrist also stated there was no discussion with the interdisciplinary team about hospitalization for psychiatric stabilization.
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