Failure to Provide Effective Behavior Management During Care for Resident With PTSD and Psychiatric Disorders
Summary
The deficiency involves the facility’s failure to provide effective and appropriate behavior management during care for a resident with significant mental health diagnoses and a history of PTSD. The resident was admitted with multiple psychiatric and neurological conditions, including schizophrenia, anxiety disorder, PTSD, panic disorder, psychosis, depression, dementia, and confusional arousals, along with physical conditions such as rhabdomyolysis, muscle weakness, chronic pain, hypertension, hypothermia, and a history of TIA. A PRN order for Olanzapine for agitation was in place, and the care plan identified that the resident could be confused and disoriented, required assistance with ADLs, and preferred showers. The plan of care also documented that the resident was non-compliant with care and treatments and experienced alterations in mood and behavior, including combative and verbally aggressive behaviors such as kicking, hitting, biting, and making false accusations. On the day of the incident, documentation showed that the resident became combative with staff and therapy during care and showering, cursing at staff and attempting to hit them with a closed fist. Redirection was attempted but was ineffective. Despite the resident’s agitation and combative behavior, staff proceeded with the shower and related care. Multiple staff members, including a PTA, COTA, CNA, and RN, were present in the room and shower area. Witness statements described the resident as verbally abusive, threatening to hurt staff if they hurt him, telling them to get out and leave him alone, and stating they were hurting him. Staff reported that these statements were made even before they physically assisted him with transfers. The resident attempted to bite and hit staff, and staff acknowledged that they did not stop care or leave the room to allow the resident time to calm down, even though they recognized that, for someone with PTSD, they would normally leave and re-approach. Staff interviews further revealed that the resident had been yelling, cursing, and swinging at staff, and that he did not like one of the male therapists, becoming more upset when he saw him. The CNA reported that the resident had been refusing to be cleaned, smelled strongly of urine, and had food on him, and that the RN had stated he had to be showered because of his condition and the need to change his bed and mattress. Staff confirmed that they continued with the shower and transfers despite the resident’s ongoing agitation and combative behavior, and that they never paused or left the room to de-escalate the situation. The DON verified there was no documentation in the progress notes of prior behavioral incidents before this date, despite staff describing the resident’s baseline as combative. These actions and omissions demonstrate that the facility did not implement effective, individualized behavior management interventions consistent with the resident’s mental health conditions, PTSD history, and care plan, leading to the cited deficiency. The incident culminated in the resident later alleging physical abuse and food withholding, although he could not provide details or identify an abuser. Staff present during the episode denied any abuse and described their actions as attempts to assist with necessary hygiene and transfers while the resident was verbally and physically aggressive. Nonetheless, the contemporaneous documentation and staff interviews show that the resident’s escalating agitation, threats, and combative behavior were met with continued, uninterrupted care and showering rather than the use of care-plan interventions such as decreasing stimulation, allowing the resident to vent with validation, determining triggers, or stepping away and re-approaching. The facility’s behavior management policy stated that behavior patterns interfering with functional capacity should be addressed to maximize dignity, independence, and self-determination, but the handling of this episode did not reflect effective application of that policy for this resident. Overall, the deficiency centers on the facility’s failure to provide appropriate behavioral and psychosocial interventions during a high-stress care interaction with a resident known to have serious mental disorders and PTSD. Staff recognized the resident’s baseline combative behavior and the need for special handling but did not adjust their approach during the incident, did not document prior behavioral patterns in the progress notes, and did not employ de-escalation strategies such as leaving the room and re-approaching. These documented actions and inactions during the shower and related care encounter form the basis of the cited failure to provide effective and appropriate behavior management services.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Address Behavioral and Psychosocial Needs: A resident with ESRD and a traumatic amputation had verbal outbursts, cursing, and derogatory language toward staff, but was not referred for behavioral health or grief counseling after his son’s death. The resident missed dialysis treatments because of behavior and a funeral conflict, and the NP, SSD, and DON confirmed there was no notification to the provider or referral to in-facility psychiatric services despite available behavioral health support.
Failure to assess and monitor suicidal ideation: A resident admitted with a painful hip fracture and no prior MH dx voiced that he would be better off dead on a PHQ-9 and later told therapy he would kill himself if he had the means. The SW documented the statements but did not notify admin, the DON, or the MD, and no MH referral or suicide precautions were implemented. Staff across disciplines were not informed of the prior suicidal comments, and the resident was later found unresponsive in bed with a cord around his neck; EMS determined the event was intentional self-harm and the death certificate listed suicide.
A resident with depression, cognitive decline, and severe cognitive impairment had an ordered psychology/psychiatry consult that was not completed for months despite ongoing agitation, refusal of care, yelling at staff, and other disruptive behaviors. The DON acknowledged the consult should have been arranged and completed, but the facility’s psych provider was on maternity leave and the covering provider did not appear, so no service was provided.
A resident made suicidal statements and later threatened to commit suicide, but the clinical record lacked evidence of a self-harm/suicide assessment or provider notification. The care plan was also not updated to include triggers, goals, or interventions for suicidal ideation, and facility leaders confirmed the gaps in the record.
Failure to identify resident-specific behavioral triggers: A resident with anxiety, depression, irritability, and trauma history was observed tearful and distressed while discussing multiple family losses and conflict with other residents and staff. Records showed psych notes about holiday-related distress, ruminating, accusations of poisoning, and mild paranoia, but the care plan did not include key triggers such as holidays/Thanksgiving, lab draws, grief, or paranoia, and did not list relaxation as an intervention.
Failure to address depression and psychosocial needs: A resident with dementia, depressive disorder, and behavioral issues had PHQ-9 scores showing mild to moderate depression, but the record did not document follow-up for the increased score or consistent implementation of behavioral health recommendations. The resident often isolated in his room, declined activities, and had care plan interventions for depression and verbal aggression that were not consistently reflected in the chart or carried out as documented.
Failure to Address Behavioral and Psychosocial Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to address known psychosocial concerns for one resident who had verbal outbursts, cursed, and used derogatory language toward staff. The resident was cognitively intact with a BIMS score of 15 and had diagnoses including end stage renal disease and a traumatic amputation of two or more right lesser toes. The Quarterly MDS identified verbal behavioral symptoms directed toward others, but the resident was not referred for in-facility psychiatric services or grief counseling despite the facility’s available behavioral health services. Record review and interviews showed that the resident missed dialysis treatments because of behavior and because one make-up dialysis appointment conflicted with his son’s funeral. The resident representative stated she was concerned about the missed medical and dialysis appointments and was not aware of any grief counseling offered after the death of the resident’s son. The DON confirmed that the resident missed dialysis because of behavior and that the resident also missed a dialysis appointment on the day of the funeral. She stated that the resident had shown a change in behavior during his stay and that staff received the brunt of his behavior. The NP stated she was not notified that the resident missed dialysis treatments and that there was no documentation that the covering NP was notified. The SSD confirmed awareness of the resident’s verbal outbursts but had not notified the primary healthcare provider and had not referred the resident to behavioral health services. The DON also confirmed that no referral was made to behavioral health contract services and that the resident’s doctor or NP was not notified that his behavior interfered with his scheduled dialysis treatments.
Failure to assess and monitor suicidal ideation
Penalty
Summary
The facility failed to ensure a resident who had voiced suicidal ideations received a mental health evaluation, monitoring, and suicide precautions after multiple staff members documented or heard statements that he would be better off dead or would kill himself if he had the means. The resident was admitted after a fall with a non-operable left hip fracture, acute pain, and moderate protein-calorie malnutrition, and he had no mental health diagnoses on admission. His baseline care plan did not include goals or interventions for depression or mental health. He also had a history of opioid and fentanyl exposure and a blood alcohol level of 15 at the hospital, and the Medical Director later documented a long-term depression history and alcohol use. On the resident’s depression screening, the Social Worker documented that the resident said he would be better off dead because of the amount of pain he was experiencing, and the PHQ-9 score was 10, indicating moderate depression. The Social Worker did not notify administration, the Medical Director, or nursing, did not begin monitoring, and did not make a mental health referral. Two days later, therapy staff documented that the resident stated he would kill himself if he had the means. Therapy staff reported the statement to the Therapy Manager and a nurse, but the information was not escalated to administration, the Medical Director, or other leadership at that time. The Medical Director later saw the resident and documented that he was miserable, upset, distraught, and in severe pain, but the depression was deferred until pain was controlled. The resident’s suicidal statements were not communicated consistently across disciplines, and staff interviews showed that multiple nurses and aides were unaware of the earlier suicidal comments. The Social Worker later met with the resident after administration learned of the statement and reported that he was no longer suicidal, but no formal assessment or psychiatric referral was completed. On the evening of the incident, the resident was described as irritated and wanting to be left alone; he also asked for his phone to be unplugged and did not want to talk with family. Later that night, he was found unresponsive in bed with the bed control cord wrapped tightly around his neck, without breathing or a pulse. EMS determined the cardiac arrest was associated with intentional self-harm by hanging, and the death certificate listed the manner of death as suicide by self-strangulation with the bed control cord.
Delayed Psychology/Psychiatry Consult for Resident With Behavioral Symptoms
Penalty
Summary
The facility failed to ensure timely completion of a physician-ordered psychology/psychiatry consult for one resident with depression, age-related cognitive decline, and cognitive communication deficit. The resident’s MDS dated 2/25/26 indicated severe cognitive impairment and problematic behaviors directed toward others, including threatening, yelling at, or cursing at staff. An order dated 7/30/25 for a psychology/psychiatry consult with follow-up treatment as indicated was present in the order summary, but there was no evidence the consult was completed during the 11-month period reviewed. Facility progress notes documented ongoing behavioral and psychological concerns during that period, including increased evening agitation, multiple outbursts toward staff, fear of staff leaving the room, refusal of care, yelling and waving her hand aggressively at staff, calling police to complain that she was being held captive, and another episode of yelling during care. During interview, the resident stated one incident reported as abuse occurred because a CNA was rushing her. The DON stated the consult should have been arranged and completed and explained that the facility’s psychology/psychiatry provider had been on maternity leave and the covering provider failed to show up, resulting in no service being provided.
Failure to Assess and Care Plan Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed suicidal ideation and signs of self-harm. The resident’s care plan meeting note dated 4/30/26 documented that the resident said he/she might as well commit suicide, but the clinical record lacked evidence that the resident was assessed for self-harm or suicide ideation, and there was no evidence that the provider was notified of the statement. A later provider communication note dated 5/10/26 documented increasing confusion and a threat to commit suicide that night. The resident’s most recent care plan update on 5/12/26 did not include goals or interventions related to suicidal ideation. During interviews on 6/2/26 and 6/3/26, the Market Clinical Lead, Social Service Director, Market Clinical Advisor, DON, and Market Clinical Lead confirmed there was no evidence the doctor had been notified, no evidence the resident had been assessed for self-harm/suicidal ideation, and no evidence the care plan had been updated to include triggers, goals, or interventions for threat of self-harm or suicide ideation.
Failure to Identify Resident-Specific Behavioral Triggers
Penalty
Summary
The facility failed to ensure behavioral triggers were identified and assessed for a resident with diagnoses including left side weakness due to a stroke, anxiety disorder, insomnia, irritability and anger, major depressive disorder, and unspecified affective mood disorder. The resident’s annual BIMS score was 15, indicating no cognitive loss. During observation and interview, the resident was tearful while discussing the deaths of their mother and brother, stated they felt alone, described multiple family losses and the deaths of three friends at the facility, and reported conflict with two other residents who antagonized them and accused them of receiving preferential treatment. The resident also reported distrust of staff, alleged that the Dietary Manager shared protected health information with other residents, stated the facility arranged an outside agency evaluation without permission, and alleged a staff member intentionally struck them with another resident’s wheelchair. Record review showed psychiatric notes documenting concern about holidays and the upcoming anniversary of the brother’s death, ruminating on past events, accusations that staff attempted to poison the resident, and mild paranoia related to state examinations and dietary restrictions. The care plan identified trauma related to the deaths of the resident’s father, mother, and brother, and identified triggers such as other residents being assisted before them and the presence of a specific resident, but it did not include holidays, especially Thanksgiving, lab draws, paranoia, grief, or relaxation as an intervention. The Social Service Director stated the resident was paranoid at times and was aware the resident had been verbally abusive to a lab technician, but was not aware the resident blamed the hospital lab for their mother’s death.
Failure to Address Depression and Psychosocial Needs
Penalty
Summary
The facility failed to ensure a resident with diagnoses including dementia with behavioral disturbance and depressive disorder received appropriate treatment and services to support mental and psychosocial well-being. The resident’s MDS showed moderate cognitive impairment, verbal behaviors toward others, and depression identified through PHQ-9 screening. The resident also received an antidepressant and an antipsychotic medication, and the record showed no gradual dose reduction attempt or documentation that it was clinically contraindicated. Record review and observations showed the resident spent much of the day in his room with the lights off and blinds closed, often sat alone in the dining room, and told staff he did not like to participate in facility activities. The care plan identified depression, self-isolation, verbal aggression, and the need for psychosocial monitoring, emotional support, activities of interest, and behavioral interventions such as calm approach, positive reassurance, one-on-one interactions, and a quiet environment. A psychiatry note also recommended a more proactive approach to encouraging the resident to attend activities, such as telling him it was time to go rather than asking if he wanted to go, but this recommendation was not reflected in the electronic record. The resident’s PHQ-9 scores showed mild depression in September 2025, then moderate depression in December 2025 and again in March 2026, but the record did not show documentation addressing the increased score, follow-up, interventions, or services offered. Physician orders included monitoring for behaviors, isolation, side effects of psychotropic medications, and offering non-pharmacological interventions, but the record showed these interventions were not consistently implemented or documented as effective. Staff interviews confirmed the resident could become upset when approached in a way that suggested he was blamed for resident-to-resident altercations, and the administrator and social services director acknowledged they could not locate documentation showing why the PHQ-9 score increased or that the behavioral health recommendation had been incorporated into the care plan.
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