Failure to Manage Resident's Psychiatric Needs Leads to Assault
Summary
The facility failed to ensure that a resident with a history of schizophrenia and aggressive, inappropriate sexual behaviors was properly evaluated and treated upon admission. The resident, who had been receiving Clozapine for disorganized thoughts and aggressive behavior at a previous facility, was not assessed by a psychiatrist or prescribed the necessary medications upon admission to the current facility. This oversight led to the resident not receiving any treatment for his schizophrenia since his admission. As a result of the facility's inaction, the resident sexually assaulted another resident twice. The first incident was witnessed by a Certified Nursing Assistant (CNA), who separated the residents but failed to maintain supervision. Shortly after, the resident assaulted the same individual again, which was witnessed by another CNA. The assaulted resident had severe cognitive impairments and was dependent on staff for daily activities, making them particularly vulnerable. The facility's failure to review the resident's psychiatric history and medication needs, as well as the lack of immediate and appropriate intervention by staff, resulted in the resident's aggressive behaviors going unchecked. This placed other residents at risk and led to the sexual assault of a vulnerable resident. The facility's Director of Nursing admitted to overlooking the resident's psychiatric history and failing to ensure the resident received the necessary behavioral care and services.
Removal Plan
- Ensure all residents are free from abuse through training addressing the critical elements of identifying all categories of abuse and the procedures for reporting abuse.
- Resident was discharged from the facility and sent to a General Acute Care Hospital for psychiatric evaluation and treatment.
- Resident was transferred to a General Acute Care Hospital for evaluation and returned to the facility.
- Upon Resident's return, the Social Services Director began monitoring Resident for emotional distress. Resident was seen by a psychologist and psychiatrist.
- The Social Services Director interviewed all cognitively aware residents and inquired if they have experienced abuse or know of any abuse in the facility. Staff were interviewed regarding residents who were not able to be interviewed.
- All residents with psychiatric diagnoses admitted will be reviewed by the interdisciplinary team for their psychiatric and behavioral needs, including their medication regimen and/or need for psychiatric consultation.
- Any residents admitted will be assessed by the interdisciplinary team for their medical, physical, and psychological needs and care planned accordingly.
- Staff training on abuse prohibition will consist of abuse prevention, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond.
- The Director of Nursing, the Director of Staff Development, and/or Clinical Resources will in-service and educate licensed nurses to review admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned.
- The Administrator, the Director of Nursing, the Director of Staff Development or Clinical Resources will in-service and educate facility staff on the immediate action required during an alleged abuse situation.
- Education and training for staff on leave, vacation, per diem or registry status will be completed prior to the start of their working shift.
- The facility Medical Director was notified of the Immediate Jeopardy and will continue to assist the facility to meet the needs of the Residents.
- Prior to the Quality Assurance Performance Improvement meeting, all training and education which includes abuse, review of admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned, separating residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision to keep a resident safe from any further alleged abuse, and all resident interviews regarding any alleged abuse, will be completed.
- This Immediate Jeopardy Removal Plan will be reviewed at the next scheduled QAPI Committee Meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with hemiplegia, hemiparesis, chronic pain, and recent bereavement repeatedly expressed suicidal ideation and later attempted suicide by strangulation using wiring from an in-room circadia device. An RN supervisor found the resident with the cable around the neck, but there was no documented notification of the provider or police, no documented removal of the ligature risk from the room, and no care plan, change-in-condition note, or IDT meeting addressing the attempt. Subsequent psych consults did not specifically evaluate or treat the suicide attempt, the circadia device and wiring remained accessible at bedside, and key staff, including the ADON and MD, reported they were not informed of the attempt, while the resident reported no follow-up evaluation and ongoing suicidal thoughts.
Failure to coordinate psychiatry services for a resident with BPD, PTSD, and MDD. The resident had an order for psychiatry follow-up, medication review for increased anxiety, and social work involvement for a possible transfer to a setting supporting her mental health, but the referral was not completed because social services was unaware of the order. The resident stated she felt unheard and misunderstood by staff and reported she was not offered additional therapy or mental health support beyond speaking with a grief therapist on an iPad.
A resident with intact cognition and diagnoses of PTSD, depression, anxiety, and panic disorder had a care plan and physician orders indicating the need for psychiatric evaluation and treatment, along with behavior and psychoactive medication monitoring. Despite this, the resident did not receive psychiatrist services; a counselor who had been visiting stopped coming and could not adjust medications, and the resident reported repeatedly requesting psychiatric care from the Social Worker and Administrator without action. The resident ultimately scheduled her own psychiatric appointment, and an LVN documented that the Administrator instructed staff to tell the resident she could not make her own appointments and must coordinate with nursing. The physician stated he had been recommending mental health services, while the Social Worker and Administrator acknowledged gaps in counseling and psychiatric services and could not provide documentation of any refusal of on-site psychiatric NP services, contrary to the facility’s behavioral health services policy.
A resident with dementia, diabetes, heart failure, and a right arm fracture was receiving Seroquel for vascular dementia without behaviors. Psychiatry recommended Keppra levels, consideration of a neurology consult, and discontinuation of Celexa due to possible mania, but the EHR showed the Keppra levels were not obtained and Celexa was not stopped. The resident later had a fall with injury and was sent to the hospital.
A resident with bipolar disorder, anxiety, chronic PTSD, and recurrent MDD, who was cognitively intact and had a PASRR Level II, was care planned to receive supportive counseling and mental health services related to a recent parental death. A psychotherapy assessment recommended and the resident agreed to psychotherapy 1–4 times monthly, and an initial note showed benefit from these services, but no psychotherapy visits were documented after that point. Despite psychiatry notes describing ongoing grief and encouraging psychotherapy, and the resident expressing a desire to talk with a therapist and requesting to see a priest, there was no documentation that counseling or grief services were provided or that services were refused, and no documented follow-through on spiritual support requests, contrary to facility policy requiring necessary behavioral health services.
A resident with multiple psychiatric diagnoses, including schizophrenia, PTSD, anxiety, psychosis, and dementia, became increasingly agitated and combative during a shower and related care. Despite a care plan noting confusion, behavioral issues, and the need for behavioral interventions such as decreased stimulation and validation, several staff members continued with transfers and showering while the resident yelled, cursed, threatened staff, and attempted to hit and bite. Staff acknowledged they did not stop care or leave and re-approach, even though they recognized this would normally be done for someone with PTSD, and there was no prior documentation of behavioral incidents in the progress notes despite reports of a combative baseline. These actions and omissions led to a deficiency for failing to provide effective and appropriate behavior management during care.
Failure to Ensure Safe Environment and Follow-Up After Resident Suicide Attempt
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and timely mental health services and environmental safety for a resident with suicidal ideation and a suicide attempt. The resident was admitted with hemiplegia and hemiparesis following a cerebral infarction, along with low back pain, weakness, and a history of falls. On one evening, an LVN documented that the resident was repeatedly yelling "I want to kill myself" and could not be distracted from suicidal ideation, and the MD was notified. A police call report from that same night documented that the resident was threatening self-harm, was upset about a recent maternal death, and was experiencing back pain. The following morning, the RNS/DON found the resident with a circadia device wire around the neck after the resident had pulled the wiring from the wall and attempted strangulation. The RNS/DON’s progress note about the suicide attempt did not document that the police or the provider were contacted, and the RNS/DON could not recall if they had been notified. The RNS/DON was unable to find documentation that the circadia wire was removed from the room after the attempt. The physician order set included an order to monitor the resident every shift for suicidal ideation and listed two psych consults, but there were no orders to remove strangulation implements from the resident’s vicinity. Psychology notes from subsequent evaluations did not include any specific evaluation or treatment related to the suicide attempt. During a later room observation, the circadia device with wiring was still present next to the resident’s bed, and the resident confirmed by nodding that this device had been used in the suicide attempt. Interviews and record reviews showed that key facility staff and the provider were not fully informed of the suicide attempt and that no formal care planning or IDT process occurred in response. The RNS/DON stated the medical record did not contain a care plan, change in condition documentation, IDT meeting, or specific interventions addressing the suicide attempt. The MD reported being notified of suicidal ideation on two occasions but not of the actual suicide attempt and stated they were not part of any IDT meeting about it. The ADON stated they had not been informed of the suicide attempt and confirmed there was no IDT meeting or care plan related to it. The resident reported they were not sent out for further evaluation and that the facility did not provide follow-up to the suicide attempt, while also acknowledging ongoing suicidal thoughts and a desire to talk about the event. The facility’s own policy required immediate 911 activation, provider and DON notification, psychiatric/psychological evaluation, and care plan updates after a suicide attempt, but these steps were not documented as having been followed in this case.
Failure to Coordinate Psychiatry Services
Penalty
Summary
The facility failed to ensure coordination of mental health care services for a resident who had diagnoses of borderline personality disorder, post-traumatic stress disorder, and major depressive disorder. The resident’s quarterly MDS identified her as cognitively intact, and a provider order dated 3/11/26 directed psychiatry to see her the following week, social work to contact the case manager to expedite transfer to a setting that would support her mental health, and changes to psychiatric medications due to increased anxiety; the resident also requested female caregivers. Her care plan identified her as at risk for altered behavior related to trauma and noted a need for referral for psychiatry services and collaboration with social services and psychiatry to improve social connections and minimize symptomology. Psychiatry provider notes were requested but not provided. During interview, the resident stated her PTSD, anxiety, and depression made her feel that she was not heard and understood by staff, and that although she used an iPad to speak with a grief therapist, she was not offered additional therapy or mental health support. Nursing staff stated therapeutic communication should be used with residents having stress-based outbursts, and the RN stated provider orders were to be followed and referrals were important for cohesive care, but she was unaware of the psychiatry referral. Social services stated the psychiatry appointment process was handled by that department and that the resident’s order was not completed because social services was unaware of it. The DON stated provider orders were expected to be entered into the medical record as soon as possible and outside psychiatric appointments were expected to be arranged per orders, but staff were unsure why the order was missed and whether the resident accepted or declined additional services.
Failure to Provide Ordered Psychiatric Services for Resident With PTSD
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services to a resident with PTSD, depression, and anxiety, in accordance with the resident’s assessed needs and the facility’s own policy. The resident was a cognitively intact female, independent with ADLs, with active diagnoses of generalized anxiety disorder, panic disorder, depression, and PTSD. Her care plan identified behavior problems including verbal aggression, crying, and isolation related to PTSD, depression, and panic disorder, with interventions such as administering medications as ordered, anticipating needs, providing opportunities for positive interaction, and discussing and reinforcing why behaviors were inappropriate. Physician orders included behavior monitoring, psychoactive medication monitoring, and an order for psychiatric services to evaluate and treat, along with multiple psychotropic medications for depression, anxiety, and insomnia. Despite these orders and identified needs, the resident did not receive psychiatric services as ordered. The physician progress note documented that the resident had PTSD, was on multiple medications, and “probably needs psych follow up,” and the physician later stated he had been recommending mental health services for her. The resident reported that since admission she had not received psychiatrist services, had repeatedly requested a psychiatrist for her PTSD and depression from the Social Worker and Administrator, and that a counselor who had been visiting her stopped coming; she noted that the counselor could not adjust medications and only talked with her. A progress note documented that the resident made her own appointment with a psychiatrist and that the Administrator directed staff to inform the resident she could not schedule her own appointments and must coordinate with nursing, even though the appointment had already been set. Interviews with facility staff further demonstrated the lack of appropriate behavioral health services. The Social Worker stated that the resident had been receiving counseling services but that the counselor relocated and they had not had one “in a while,” and that he only comes once a week to visit the resident. The Administrator stated that the resident had refused to see the psychiatric NP who comes to the facility since admission but was unable to produce documentation of any such refusals and acknowledged not knowing why the facility had not attempted to obtain services from a different mental health entity. The Administrator also confirmed that the resident had made her own psychiatric appointment and would be going to it. The facility’s behavioral health services policy stated that residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and that residents exhibiting emotional or psychosocial distress receive services and support addressing their individual needs, but the facility did not follow this policy for this resident.
Failure to Follow Psychiatry Recommendations for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure recommendations from mental health consultations were followed for Resident 11, who was admitted with diagnoses including a right arm fracture, dementia, diabetes, and heart failure and was unable to communicate needs. Review of the significant change MDS showed the resident was receiving an antipsychotic medication and had experienced a fall with injury. A provider order dated 03/10/2026 showed Seroquel 25 mg twice daily for vascular dementia without behaviors. Psychiatry evaluated Resident 11 on 03/06/2026 and recommended Keppra levels and consideration of a neurology consultation. Psychiatry evaluated the resident again on 03/11/2026 and recommended discontinuing Celexa due to potential side effects of mania. The EHR showed Keppra blood levels were not obtained and the recommendation to discontinue Celexa was not followed. Resident 11 later had a fall with injury on 03/19/2026 and was sent to the hospital. During interview, the RCM/LPN stated the process was to read specialist recommendations such as psychiatry and follow up on them, and stated Resident 11's psychiatric recommendations should have been completed.
Failure to Provide and Document Behavioral Health and Grief Services
Penalty
Summary
The facility failed to provide necessary behavioral health services and grief support to a resident with multiple mental health diagnoses and a history of trauma-related conditions. The resident had diagnoses including bipolar disorder, anxiety disorder, chronic PTSD, and recurrent MDD, and was cognitively intact with a BIMS score of 15. The resident’s care plan, including a PASRR Level II without specialized services and a separate plan addressing the recent death of the resident’s mother, called for supportive counseling and offering mental health services as needed. A psychotherapy diagnostic assessment from 9/22/2025 indicated psychotherapy 1–4 times per month would be beneficial and that the resident was agreeable to this frequency. Psychotherapy notes from 10/21/2025 documented that the resident was participating in and benefiting from psychotherapy. However, there were no further psychotherapy notes after October 2025, and no documentation that the resident declined ongoing psychotherapy, despite the psychiatrist’s 2/17/2026 note encouraging the resident to speak with the psychotherapist about grief and the 4/6/2026 note indicating the resident was looking forward to talking with the psychotherapist. The resident reported that she had only met with the therapist a few times months earlier and did not know why the therapist stopped coming, and stated that no one from the facility or other grief service providers came to speak with her after her mother’s death, despite her requests to talk to someone and to see a priest. Progress notes on 4/3/2026 documented the resident’s request to see a priest after reporting she had lost faith when her mother passed away. The DON stated the therapist had not seen the resident since October 2025, that the therapist attempted a visit in November 2025 which the resident refused, and that the therapist did not document this refusal. The DSS acknowledged calling for a priest to see the resident but had no documentation of the earlier request and confirmed there was no documentation of counseling services provided to the resident after her mother’s death, despite her own verbal report of meeting with the resident. The facility’s policy dated 3/5/2024 required that all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning, which was not met in this case.
Failure to Provide Effective Behavior Management During Care for Resident With PTSD and Psychiatric Disorders
Penalty
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
