F0658

E

Failure to Provide Behavioral Health Training, Review Policies Annually, and Implement Multidisciplinary Vent Weaning Plan

Fresno, California Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The facility failed to follow its policy requiring behavioral health training for all staff working in the Special Treatment Program (STP) behavioral health unit. An anonymous complainant reported that Activity Assistants were being sent into the STP to assess residents’ activity needs without the required behavioral health training. The STP Director confirmed that all employees working in the STP were required to have behavioral health training for their safety and the safety of residents. The Director of Staff Development’s review of the behavioral health training records showed that two Activity Assistants were not listed as having completed the training, and he was unsure whether Activity Assistants were required to have it. During interviews, three Activity Assistants stated they were required to go into the STP unit to perform activity assessments and revise residents’ activity care plans; two of them reported they had requested behavioral health training due to safety concerns but had not received it. The Administrator later confirmed that only one Activity Assistant was documented as having any behavioral health training, and certificates showed partial training for two Activity Assistants and no training documentation for two others.

The facility also failed to follow its own policy requiring annual review of policies and procedures. During review with the DON and Administrator, the facility’s policy titled “Ventilation, Weaning a Patient from Mechanical,” last dated 7/31/2017, was found to have no documented review since that date. The Administrator acknowledged that policies and procedures should be reviewed annually. Another facility policy titled “Facility Policy and Procedures – Annual Reviews,” last revised 10/2018, stated that policies and procedures are to be reviewed as needed and at least annually, with revisions made as necessary to reflect current operations, regulatory requirements, and accepted standards of care, and that the QAPI committee reviews and revises policies at least annually.

In addition, the facility did not implement its ventilator weaning policy for a resident admitted for ventilator weaning. A complainant reported that this resident had been admitted nine months earlier for ventilator weaning, that weaning trials had stopped, and that neither the resident nor the complainant could obtain information on the facility’s ventilator weaning policy from Respiratory Therapists (RTs). Physician orders directed ventilator weaning “as tolerated” with documentation of tolerance and hours, and noted the resident’s Guillain-Barré Syndrome and the need for patience in weaning. RT documentation on one date indicated that cool mist was paused to wean off the ventilator until the following week for reevaluation, but the RT could not locate the required follow-up reassessment. One RT could not state the facility’s current ventilator weaning policy or how to access it and reported relying on personal experience. Another RT, when reviewing the written policy, stated she was unfamiliar with the requirement to develop a multidisciplinary weaning plan and had not used one. The policy required a multidisciplinary plan specifying start time, mode, duration of weaning trials, and monitoring and rest periods, but the resident’s ventilator weaning order entered by an RT lacked these specific elements and did not document the multidisciplinary participants.