F0740

G

Failure to Implement Behavioral Care Plan and CPI Techniques During Resident Crisis

Kansas City, Missouri Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to provide necessary behavioral health services and to implement the person‑centered behavioral care plan and CPI de‑escalation techniques for one resident with complex psychiatric and neurocognitive diagnoses. The resident had schizoaffective disorder bipolar type, Bipolar I disorder, DMDD, ODD, borderline personality disorder, PTSD, autism spectrum disorder, traumatic brain injury, and an unspecified neurocognitive disorder related to self‑harm brain injury. The PASRR and care plan documented high‑risk behaviors, history of violent temper, multiple psychiatric admissions, suicide attempts, self‑injurious head‑banging, and the need for a safe, secure setting. The care plan directed staff to ensure a safe environment, avoid confrontation and power struggles, be mindful of personal space, closely monitor for agitation, decrease stimulation, and use specific coping skills such as music with headphones, computer use, reading, writing, and diamond art, as well as weekly meetings with the Administrator as desired.

On the evening of 03/06/26, a behavioral incident began on the smoke deck where the resident and the DON were yelling at each other, with the resident upset about limits on calling a parent/guardian. The resident, who was on one‑to‑one monitoring for safety, became increasingly agitated, broke a plexiglass mirror, and obtained sharp plastic pieces. Staff called a behavioral Code. According to staff interviews, LPN A was able to get several pieces of plastic away from the resident and was talking with the resident when the DON entered the room. The resident picked up another sharp piece, threatened self‑harm, and also threatened to stab the DON if approached. Witnesses reported the DON picked up a jagged piece of plastic and made antagonistic statements, and the DON did not remove themself despite being identified as a trigger for the resident. The DON blocked the resident’s doorway with their body, preventing the resident from leaving, contrary to the care plan direction to avoid confrontation and be mindful of personal space.

Video footage and multiple witness statements showed that when the resident exited the room and backed down the hallway, the DON followed closely, continued to engage, and initiated physical contact rather than fully utilizing verbal CPI de‑escalation and the resident’s coping strategies. The DON extended arms toward the resident’s clavicle/neck area, pushed the resident against the wall, and attempted a physical hold. The facility’s internal investigation and witnesses, including RN A and LPN A, described the DON’s hand or forearm placement near the resident’s neck or collarbone, with the resident yelling that the DON was choking them. The investigation concluded CPI techniques were not correctly or fully used, that contact with the resident’s neck area occurred despite this being strictly prohibited, and that the DON blocked the resident in the room, followed the resident into the hall, yelled, entered the resident’s personal space, and failed to use the resident’s identified coping skills or person‑centered interventions. The resident was later observed with a 9‑cm red scratch from below the jawline to above the collarbone and reported being choked and scratched by the DON, feeling unsafe, and having nightmares about being strangled by staff. Psychiatric NPs and the Corporate Director of Behavioral Health Services stated staff did not follow CPI principles, did not consistently use the resident’s coping skills or care plan, and that the DON should have disengaged once other staff were present, but instead escalated the situation, resulting in unnecessary physical contact and psychosocial distress for the resident.