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 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 depression and chronic anxiety, who had intact cognition and an order for psychology consult and treatment as needed, reported that a CNA interacted with her in a threatening and aggressive manner, after which she experienced increased nocturnal anxiety, fear of falling asleep, and later stated she did not feel safe. Despite these documented emotional and behavioral changes, no behavioral or change-of-condition assessment was completed, no psychologist notes were present, and the care plan was not revised to address the new behavioral health symptoms. Facility staff, including social services and the MDS coordinator, confirmed that required behavioral assessments were not done, and the DON was unaware of the resident’s expressed lack of safety, contrary to facility policies on behavioral assessment, trauma-informed care, and comprehensive person-centered care planning.
A resident with a history of aggressive and unpredictable behavior did not receive necessary behavioral health care and services, as outlined in their care plan, leading to a physical altercation that caused harm to another resident. Despite staff awareness of the resident's behavioral issues and the implementation of a 1:1 sitter for safety within the facility, the resident was allowed to go out on pass without supervision, and repeatedly declined psychological services.
A resident with a history of agitation was involved in a verbal altercation with another resident and attempted to hit them, prompting an IDT care conference that recommended a psychiatric evaluation and treatment for agitation. The physician entered an order for a psych evaluation, but the ADON and social services staff were unsure whether the referral was completed, and the SSA, who was responsible for sending referrals, had no access to the psychiatrist’s portal and found no psych notes in the EHR. The DON confirmed the order for psychiatric services, the absence of psychiatric documentation in the chart, and acknowledged that without the psychiatrist’s recommendations the facility would not be compliant with psychiatric services and the resident’s psychosocial health would be affected.
A resident with end stage renal disease, diabetes, and dementia repeatedly left the facility without permission and missed dialysis appointments, yet the facility did not implement or document behavioral interventions, care plan revisions, or interdisciplinary team involvement as required. The facility also failed to communicate with the resident's family or emergency contacts and did not initiate a psychiatric evaluation as ordered.
A resident with multiple behavioral health diagnoses, including PTSD and major depressive disorder, repeatedly exhibited extreme agitation, verbal and physical aggression, and used racial slurs toward a roommate and the roommate’s family. Despite documented incidents and ongoing complaints, the facility’s interventions were limited and did not effectively address the resident’s behavioral health needs, resulting in continued risk and negative psychosocial impact on others.
A resident with Alzheimer's disease and a history of behavioral disturbances, including hitting and yelling at staff and other residents, was not properly assessed or care planned for these behaviors. Staff observed and reported the behaviors, but the MDS did not reflect them, and there was no care plan in place prior to documented altercations. Facility policy required behavioral assessment and care planning, which was not followed.
A resident with a history of stroke and colon cancer, experiencing sadness and depression, did not receive a timely psychiatric evaluation after a referral order was entered. The Social Services Department failed to process the referral, and the resident reported not being offered counseling or therapy. Interviews confirmed the referral was not completed as required by facility policy.
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