Failure to provide behavioral health care and a care plan for a resident with psychosis and agitation: A resident with mood disorder, psychosis, dementia with psychotic disturbance, and schizophrenia-related behaviors was admitted with agitation, striking out, and restlessness, but the baseline care plan had no behavioral interventions. Staff later documented uncontrolled restlessness and agitation, the resident was receiving antipsychotic, antidepressant, and PRN anxiolytic meds, and the facility realized after admission that the resident needed 1-to-1 supervision. The resident was sent back to the hospital because the facility could not accommodate the sitter requirement.
Failure to provide behavioral health evaluation and services: A resident with anxiety, depressive episodes, and a personality disorder had a PASRR Level II trigger, psych consult orders, and multiple psychotropic medications, but the record showed no documented mental health referrals or Level II completion. The chart also showed repeated behavioral symptoms, verbal aggression, refusal of care, delusional statements, self-induced vomiting, and statements about wanting to die, while the IDT did not document review of behavioral symptoms or response to medications. The SSD and DON acknowledged missing documentation and that the resident’s behavioral health needs were not fully evaluated.
Failure to provide necessary behavioral health services for two residents. One resident with depression, paranoid personality disorder, and mood disorder reported daily and nightly fear, while staff described ongoing paranoia, isolation, and a lack of consistent counseling and psych services after the facility lost counseling coverage and had limited psychiatrist availability. A second resident with depression and cognitive impairment stated they would rather be dead and reported no mental health services or social services visits, while staff noted the resident was withdrawn, grieving a brother’s death, and waiting for psych services.
Failure to Address Aggressive Behavior and Refusals of Care: A resident with schizoaffective disorder bipolar type had repeated verbal aggression, agitation, and refusals of care and meetings, yet the facility did not develop effective individualized behavioral interventions. Records and staff interviews showed ongoing yelling, abusive behavior, and refusal of psychiatric evaluation, treatment, activities, and services. The resident later became involved in a verbal and physical altercation with another resident near the nursing station, after staff described a pattern of aggressive episodes and inability to manage his behaviors.
Failure to assess and monitor a resident’s behavioral health needs. A resident with hx of bipolar disorder, schizoaffective disorder, and PTSD reported ongoing distress related to combat trauma and difficulty getting staff to listen. Although the care plan addressed trauma, triggers, and support needs, the RN Supervisor stated there was no physician or nursing documentation of behavioral monitoring or trigger assessment, and that an order was needed to implement behavior monitoring.
A resident with major depressive disorder was receiving Paxil 20 mg daily for depression, but nursing staff did not monitor for adverse reactions as required by facility policy. The DON confirmed that the resident had been on Paxil for an extended period with no orders for adverse reaction monitoring and no shift-to-shift assessments documented. The facility’s psychotropic medication policy requires licensed nurses to observe for adverse reactions, notify the physician if they occur, and document both the reactions and the communication, but this was not done for this resident.
Failure to provide behavioral health services for a resident with MDD, delusional disorder, and trauma history. The resident’s care plan identified disturbed thought processes, depression, and suspected trauma history, and included a referral to Psychiatry or a mental health provider, but the record showed no psych consult or referral. The resident reported a home invasion and said a prior hospital psychiatrist did not believe the trauma was real; the DON stated psych services should be provided if indicated on the care plan.
Failure to Document Target Behaviors for Psychotropic Medications: A resident with paranoid schizophrenia and schizoaffective disorder was prescribed Haldol and Risperdal for specific behavioral symptoms, but staff did not document the targeted behaviors on the MAR as ordered. The record included an SBAR for severe agitation requiring law enforcement involvement and a hospital transfer, while observations showed the resident talking to self, laughing, smiling, and pacing. RN, LVN, and DON statements confirmed that target behaviors such as agitation, yelling, pacing, and anxiety should have been documented and tallied for review.
A resident with schizoaffective disorder and depression, assessed as cognitively intact, began refusing multiple medications (including psychotropics), meals, blood sugar checks, and ADL care, while exhibiting delusional thoughts and escalating behavioral changes such as calling law enforcement, yelling at staff, and repeatedly refusing showers and incontinence care. Nursing notes and IDT documentation reflected ongoing refusals and impaired cognition, and CNAs reported the resident frequently declined hygiene care despite noticeable odor. Although a psychiatric consult was eventually ordered, it was delayed and not completed before the resident was transferred to the hospital for continued refusal of food, medications, and basic care, resulting in a failure to provide necessary behavioral health care and services as outlined in facility policy.
A resident with intact cognition and significant medical needs, including trach ventilation and wheelchair use, had documented inappropriate sexual behavior toward female CNAs, including sexual remarks, requests for intimate care he could perform himself, and an incident of exposing himself. Although the care plan called for behavior monitoring and psychiatric consult as needed, staff interviews and record review showed no specific behavioral monitoring, no physician notification, and no psychiatric evaluation to assess the behavior.
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