Failure to Implement Behavioral Health and Safety Protocols During Resident Altercation Over Personal Property
Summary
The deficiency involves the facility’s failure to implement its behavioral health practices and procedures when two residents with significant psychiatric histories escalated from a verbal dispute into a physical altercation resulting in injury. One resident had a PASRR diagnosis of schizophrenia with a history of difficulty getting along with others, frequent altercations, evictions, fear of strangers, and failed placements in less restrictive environments due to aggressive behaviors. The other resident had PASRR diagnoses including schizoaffective disorder bipolar type, Bipolar I Disorder, Major Depressive Disorder, psychosis, schizophrenia, and epilepsy with potential cognitive impairments such as memory loss, slow processing, and poor safety awareness. Both residents’ care plans and ICSPs identified triggers related to theft or loss of belongings, people getting into their personal space, and being bullied, and listed individualized coping strategies such as drawing/painting, going outside, smoking, having coffee or soda, and watching TV. The sequence of events began when an activity aide, who reported never being educated on how to receive and distribute packages, gave a package to one resident after confirming the name on the package, not realizing that the resident’s first name matched another resident’s last name. The package actually contained jeans intended for the other resident. The resident who received the package later realized the jeans were not his/hers and decided to sell them to another resident. The intended recipient discovered the jeans were missing and confronted the resident who had received and attempted to sell them. Staff, including a CNA and a CMT, reported that they heard or observed a verbal argument between the two residents about the pants and that residents in the facility often became upset when others borrowed, stole, or sold their belongings, with such issues frequently leading to fights. Despite facility expectations and staff education that a behavioral emergency Code [NAME] should be called as soon as a verbal altercation or escalation was observed, staff did not initiate the code at the onset of the argument. CMT A acknowledged responding to the verbal altercation but did not call the code until seeing scissors in one resident’s hand, and CNA A stated he/she heard yelling, went to the residents, and tried to break up the fight without calling a code when the situation was still verbal. During the altercation, both residents exchanged punches, and one resident produced a broken pair of scissors and stabbed the other in the left forearm. Staff then intervened using CPI techniques, separated the residents, and removed the scissors. The injured resident was transported to the hospital, where records documented a stab wound to the underside of the left forearm that required repair and staples, and a concussion with a neck brace. The facility’s own investigation substantiated that resident property was mishandled, staff identified the argument but did not intervene soon enough to separate the residents, and the delay in calling Code [NAME] and failure to promptly remove scissors from the resident contributed to the physical altercation and resulting injury. Additional deficiencies in behavioral health coordination and safety procedures were identified. The facility’s behavioral health policy required close monitoring for distress, documentation of behavioral changes and triggers, and multidisciplinary team involvement, including psychiatric input, when behaviors occurred. However, review of the injured resident’s medical record showed no documentation that the psychiatric nurse practitioner was notified of the resident-to-resident altercation, despite the PNP’s expectation to be informed of every incident and behavior to provide appropriate recommendations. The facility’s policy on screens/searches upon entering the facility required all sharp objects to be secured by staff and not kept with residents, yet one resident reported keeping scissors locked in a drawer in his/her room and using them for art, and the DON and administrator both stated that staff should always retrieve scissors from the resident after use and that the resident should never have kept scissors in the room. Staff also reported that they had not reviewed the residents’ ICSPs and were not familiar with their specific triggers and interventions, even though the ICSPs contained detailed behavioral triggers and coping strategies intended to guide staff responses. These combined failures to follow behavioral health policies, emergency response procedures, contraband/sharp object controls, and psychiatric notification requirements led to the escalation of a known trigger situation into a serious resident-to-resident physical altercation with injury. The facility’s own Registered Nurse Investigation documented that the incident was substantiated as physical aggression not involving the head, arising from mishandling of resident property and delayed staff intervention. Staff statements and interviews with the DON, administrator, and PNP confirmed that the Code [NAME] was not called at the first sign of verbal escalation, that staff did not consistently remove scissors from the resident after use, that front desk/package-handling staff were not fully educated on package protocols, and that the PNP was not notified of the behavioral incident. Observations of the injured resident after return from the hospital showed a healing wound on the left forearm with staples removed and surrounding redness. These facts collectively demonstrate that the facility did not ensure residents received necessary behavioral health care and services in accordance with its own policies, did not adequately implement crisis prevention and intervention practices, and did not maintain environmental and procedural controls (including contraband/sharp object management and package handling) necessary to support residents’ mental and psychosocial well-being and safety. The deficiency is further supported by staff acknowledgments that resident-to-resident altercations frequently occur over borrowing, stealing, or selling items, and that many residents are triggered when their belongings are taken or tampered with. Despite this known pattern and the specific triggers documented in both residents’ care plans and ICSPs, staff involved in the incident had not reviewed those plans and were unaware of the residents’ individualized triggers and de-escalation strategies. The facility’s behavioral health policy required staff to monitor for distress, evaluate behavioral changes, and develop person-centered care based on identified concerns, but in this case, staff did not use the available information on triggers and coping skills to intervene early or redirect the residents before the situation escalated. The lack of timely behavioral emergency activation, failure to secure sharp objects, improper handling of resident property, and absence of psychiatric notification after a significant behavioral event collectively demonstrate a failure to provide necessary behavioral health care and services as required by the facility’s own policies and procedures.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to identify and monitor target behaviors for a resident with depression. A resident with major depressive disorder, spinal stenosis, and moderately severe depression was on antidepressant and antipsychotic medications, but the care plan, provider order, and TAR did not clearly identify specific behaviors to monitor. Staff documented behavior monitoring on the TAR, yet no target behaviors were identified in the record, and progress notes lacked evidence of any behaviors. During interview, the resident described feeling very depressed and losing interest in prior activities, while RN-A, the DON, and the CP all acknowledged the monitoring order did not clearly define what behaviors staff should be watching for.
A resident with major depressive disorder, depression symptoms, and suicidal thoughts did not receive continued behavioral health services as reflected in the record. Psychiatry notes documented loneliness, grief, poor sleep, low interest, and suicidal thoughts without plan or intent, and therapy was referred, but there were no later psychiatry notes, no scheduled therapy follow-up, and the care plan lacked non-pharmacological interventions. Staff also did not have the psychiatry information in the EMR, and the SSD and ADON were unaware of key mental health findings and documentation gaps.
Failure to provide recommended behavioral health follow-up for two residents. One resident with anxiety, bipolar disorder, and major depressive disorder, and another resident with anxiety and depression, both had care plans and psychiatric consults recommending therapy/LPC follow-up, but there was no documented evidence they received the ordered psychiatric or psychological services. The DON confirmed the missed follow-up services.
Failure to Address Wandering Resident Entering Another Resident’s Room: A resident with dementia and a known wandering pattern repeatedly entered another resident’s room after staff were told the other resident did not want him/her there. No additional behavior interventions were put in place at that time, and the wandering resident later entered the room again, was pushed out by the other resident, and sustained a facial fracture.
A resident with depression, dementia, Parkinson's disease, macular degeneration, and anxiety voiced suicidal statements and expressed loneliness and feeling trapped, but the EHR did not show a referral for behavioral health talk therapy. The DON was unaware of the statements, and the NP stated the resident should have been referred for behavioral health services after reporting self-harm thoughts.
Failure to Individualize and Revise Behavioral Health Interventions for Alcohol-Related Behaviors: Two residents with substance use and mental health histories continued to drink and display alcohol-related behaviors, including slurred speech, odor of alcohol, and repeated intoxication. One resident had dementia, anxiety, and depression; the other had TBI, depression, psychotic disorder, and substance use disorder. Despite existing care plan interventions, staff interviews and records showed ongoing alcohol use, limited monitoring of triggers and target behaviors, and a resident-to-resident altercation on the smoking patio that involved yelling, physical contact, and police response.
Failure to Identify and Monitor Target Behaviors for a Resident With Depression
Penalty
Summary
The facility failed to identify and appropriately monitor target behaviors for one resident who was reviewed for mood and behavior. The resident had an admission MDS that identified intact cognition, moderately severe depression, no exhibited behaviors, and use of antidepressant medications. The resident’s diagnoses included major depressive disorder and spinal stenosis, and the care plan noted potential for adverse drug reactions related to daily psychotropic medication use. The care plan also identified alteration in mood and behavior related to diagnoses, adjustment to placement, and loss of independence, and instructed staff to monitor target behaviors and ADRs as ordered. The resident’s PHQ-9 assessment showed a score of 19, indicating moderately severe depression. Provider orders and the TAR directed staff to monitor target behaviors, but the specific behaviors were left blank, and the record did not identify any target behaviors for monitoring. The TAR was documented as completed on nearly every shift, with interventions documented on seven occasions, yet no target behaviors were identified and the progress notes from the review period lacked evidence of any behaviors occurring. During interview, the resident stated feeling very depressed, not liking reliance on others, and having lost interest in prior activities. RN-A stated staff should document observed behavior and interventions, but also said she was not really sure what she should be monitoring for the resident. The DON stated target behaviors should have been identified so staff knew what to watch for, and the CP stated the order failed to identify the specific medication or generic category and did not provide instruction for actual behavior monitoring.
Failure to Provide and Track Behavioral Health Services for Resident with Depression and Suicidal Thoughts
Penalty
Summary
The facility failed to ensure continued behavioral health services were provided for a resident with major depressive disorder, depression symptoms, and suicidal thoughts. The resident told surveyors she felt like giving up, had lost interest in activities, worried about finances, and had previously received counseling that she believed had helped, but she did not know why those counseling sessions stopped. Her record showed repeated PHQ-9 assessments with depression symptoms, including mild to moderately severe scores, and a psychiatry evaluation documented loneliness, grief, poor appetite and energy, daily anxiety, and suicidal thoughts without a plan or intent. The resident’s psychiatry notes showed that her antidepressant therapy was changed multiple times, a follow-up appointment was planned, and a referral was made for mental health therapy because the psychiatrist felt therapy would be beneficial. However, there were no psychiatry visit notes after the initial and follow-up visits reviewed, and the resident was not scheduled for the therapist referral or a psychiatry follow-up appointment. The care plan focused on antidepressant medication and monitoring for side effects and ongoing depression symptoms, but it did not identify any non-pharmacological interventions for depression. Staff interviews showed gaps in communication and documentation related to the resident’s mental health needs. The SSD stated she thought counseling had been offered, but there was no documentation that it was offered or declined, and she did not document her conversations with the resident. The ADON stated psychiatry notes were not in the EMR or reviewed before surveyor request, and she was unaware of the resident’s additional diagnoses, suicidal thoughts, PHQ-9 results showing moderately severe depression, or the therapy referral. The facility policy required assessment, individualized services, and consistent implementation of care approaches for residents with mental health issues.
Failure to Provide Recommended Behavioral Health Follow-Up
Penalty
Summary
The facility failed to consistently provide necessary behavioral health services to meet the behavioral health needs of two residents. The facility’s Behavioral Health Services policy stated that residents should receive necessary behavioral health services to help them reach and maintain their highest level of mental and psychosocial functioning. Resident 8 was admitted with anxiety disorder, bipolar disorder, and major depressive disorder, and a June 2026 MDS showed the resident was cognitively intact with a BIMS score of 15. The care plan identified risk for mood changes related to major depressive disorder, anxiety, and adjustment disorder, with psychiatric consult and treatment as ordered. A psychiatric consultant recommended therapy services for anxiety and depression with follow-up in 45 to 60 days, and an LPC later documented a follow-up talk therapy session and recommended another follow-up, but there was no documented evidence that the resident received the recommended psychiatric or psychological follow-up services by the end of the survey. Resident 61 was admitted with anxiety disorder and depression, and a quarterly MDS showed moderately impaired cognition with a BIMS score of 9. The care plan identified risk for mood changes related to depression and episodes of anxiety, with psychological consultation and treatment and LPC consultation as needed. A psychiatric consultant recommended therapy services for anxiety, depression, insomnia, and dementia with follow-up in 14 to 21 days, and an LPC documented a follow-up talk therapy session and recommended another follow-up, but there was no documented evidence that the resident received the recommended psychiatric or psychological follow-up services by the end of the survey. During an interview, the DON confirmed that both residents did not receive the recommended follow-up psychiatric and psychological services.
Failure to Address Wandering Resident Entering Another Resident’s Room
Penalty
Summary
The facility failed to timely assess a behavior change and timely implement additional behavior interventions for a resident with a history of wandering. The resident had diagnoses of unspecified dementia, mood disorder, and adjustment disorder with mixed anxiety, and the annual MDS showed moderately impaired cognitive skills with long- and short-term memory problems. The resident’s care plan identified wandering into other residents’ rooms and noted the resident was at risk for elopement, with interventions including checking code alert placement each shift and consulting with the MD and psychologist as needed. On 04/15/2025, another resident with dementia and mood disturbance told the SSD and ADON that the wandering resident had come into his/her room and that he/she did not want the resident in the room. The SSD documented that the resident wanted to be left alone and that staff said they would discuss it with the other resident and tell him/her not to come into the room. The record did not show that interventions were added that day to prevent the wandering resident from entering the other resident’s room. On 04/16/2025, the wandering resident entered the other resident’s room again, and the other resident pushed the wandering resident out of the room, causing a fall and a fracture to the left maxillary sinus wall and lateral border of the left orbit. Interviews with staff showed the wandering resident had been observed going into the other resident’s room multiple times, staff had been notified, and the DON stated the resident was on general supervision with a code alert monitor. The DON also stated the incident could have been prevented by moving the wandering resident, and the facility substantiated abuse.
Failure to Refer Resident for Behavioral Health Services After Self-Harm Statements
Penalty
Summary
The facility failed to ensure a resident with major depressive disorder, Parkinson's disease, macular degeneration, Alzheimer's disease, and anxiety disorder received necessary behavioral health care after he exhibited worsening emotional distress and voiced self-harm statements. The resident's care plan documented fluctuating mood symptoms related to sadness, depression, changes in relationships, and personal loss, and directed staff to refer him to behavioral health as needed. A change-in-condition note documented that the resident was crying in his room and stated that he wanted to die because he had no friends, could not leave the facility, and felt like he was in a prison; the provider was notified. However, the electronic health record did not show a referral to behavioral health services for talk therapy after these statements, and there were no physician orders or communication indicating such a referral. The DON stated she was not aware of the resident's statements, and the NP stated that a behavioral health talk-therapy referral should have been made after the resident's statements, but it did not occur.
Failure to Individualize and Revise Behavioral Health Interventions for Alcohol-Related Behaviors
Penalty
Summary
The facility failed to develop, implement, monitor, and revise individualized behavioral health interventions for two residents with alcohol-related behaviors. One resident had diagnoses including non-Alzheimer's dementia, anxiety, and depression, was independent with his wheelchair and most ADLs, and had care plan focuses addressing substance abuse, antidepressant medication, and community life. His record showed a history of suicidal ideations, sadness, low self-esteem, withdrawal, ineffective coping, loneliness, alcohol use, and occasional cocaine use. Although multiple interventions were listed, including discussion of treatment options, observation for behavior patterns and triggers, room checks for smoking, encouragement of activities, and supervision of peer interactions, the record also showed ongoing alcohol use with repeated notes of slurred speech and strong odor of alcohol, including episodes where medications were held and fall precautions were used. The second resident had traumatic brain injury, malnutrition, depression, and psychotic disorder, and used antipsychotic and antidepressant medication. His care plan addressed substance use disorder, mood, and antipsychotic medication, and noted a history of alcohol dependence, stimulant dependence, and cocaine dependence. Interventions included coping skills education, non-pharmacological interventions, discussion of treatment options, and monitoring of mood and alcohol-related behavior. Despite this, the resident continued to have alcohol-related incidents, including intoxication, slurred speech, altercations, and repeated behavioral concerns. The record also showed that staff were not aware of resident-specific care plan interventions regarding intoxication management, and the facility representatives later stated there were no activity recommendations or care plan changes after the incident. On the smoking patio, the two residents were drinking together and became involved in an altercation that drew police involvement. Witnesses and staff described the first resident as intoxicated, loud, belligerent, and aggressive, with repeated requests for cigarettes, while the second resident was also drinking and was involved in the confrontation. Accounts differed on the exact sequence, but the incident involved yelling, physical contact, and a cane being used. Staff interviews showed that some staff did not intervene, some were unaware of the incident in real time, and the overnight nurse was helping elsewhere when the police arrived. The facility later reviewed the event and noted that the residents had been educated about respecting each other and not sharing cigarettes, but the records reviewed showed no individualized behavioral health plan revisions tied to the ongoing alcohol-related behaviors and the resident-to-resident altercation.
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