A resident with a history of cerebral infarction and cognitive communication deficit was care planned as being at risk for elopement due to confusion, inability to express needs, and repeated statements about wanting to leave and go home. Interdisciplinary documentation described a consistent pattern of exit-seeking behaviors, including leaving on LOA with a family friend and not returning until the next day, requiring EMS assistance and hospital evaluation upon return, and later being found off facility grounds along a roadside. Despite these ongoing behaviors and the facility’s written Behavior Management Program requiring monitoring forms for residents with problematic behaviors, the clinical record contained no behavior tracking or monitoring specific to the resident’s exit-seeking behaviors, and staff acknowledged that such monitoring should have been in place.
The facility failed to monitor and develop individualized interventions for sexually focused behaviors in multiple cognitively impaired residents. Several residents with dementia had documented histories of inappropriate touching, hypersexuality, or intimate relationships with other residents, yet behavior monitoring orders and tools focused only on depression, anxiety, or general boundary issues. One resident was observed performing oral sex on another resident, and another was found receiving oral sex, while another made explicit sexual comments and requests to CNAs. Care plans for companionship emphasized hand holding and social engagement but did not include specific monitoring or tailored interventions for sexual behaviors, and the facility had no formal assessment for sexual behaviors despite policy requiring daily monitoring of target behaviors and social services involvement in behavior care planning.
A resident with multiple serious mental health diagnoses, including bipolar disorder, PTSD, anxiety, panic disorder, delusional disorder, and dementia, was admitted after an extended psychiatric hospitalization with orders and consent in place for psychiatric services, counseling, and medication management. Despite a PASSAR requirement for individual therapy and care plans calling for psychiatric referrals, counseling, and supportive group or one-on-one therapy, the clinical record showed no documented mental health services over extended periods, and the resident reported not receiving therapy and wishing to attend it. Staff, including a unit manager and the DON, confirmed the resident was not currently being seen by a psychiatric provider or receiving mental health services, and the facility lacked a policy on mental health services.
A resident with bipolar disorder, morbid obesity, and diabetes repeatedly refused a prescribed trazodone 50 mg dose for insomnia over multiple days, later reporting passive suicidal ideations and emotional distress. Although the MAR documented numerous refusals and a behavioral health note described an ED visit for passive suicidal ideation and concerns about antidepressant inconsistencies, there was no documentation that the physician was notified of the refusals until the medication was discontinued. The SSD and Social Service Assistant were unaware of the trazodone prescription and the refusals, and the refusals were not discussed in clinical meetings as was customary, contrary to the facility’s documentation policy requiring recording of services and changes in condition.
Failure to care plan resident grief and mood symptoms: A resident with bipolar disorder, depression, schizophrenia, and anxiety reported severe grief after his mother’s death, including sadness, hopelessness, paranoia, anxiety, crying, and insomnia. Records showed treatment refusal tied to depression, a psychiatry note identifying significant grief-related symptoms, and limited social service documentation, but no care plan with specific interventions to monitor or address his mood and behavior.
A resident with anxiety, depression, Huntington’s disease, and a history of aggressive behavior had a care plan identifying risk for physical aggression and an intervention to analyze and document triggers and de-escalation strategies. On one night and early morning, staff observed the resident pacing the hallway, repeatedly opening and shutting his door, and playing his TV at maximum volume, becoming upset when asked to close his door and refusing, with increased behaviors noted. Despite this escalation and prior assessments documenting aggressive tendencies, the resident later approached the nurses’ station and suddenly punched another resident in a wheelchair in the face, knocking him backward and kicking him, then cursed, threatened, and lunged at staff, attempting to hit an LPN. The DON reported the resident had strong behaviors and agitation with limited observable signs before negative behaviors, demonstrating a failure to ensure his emotional and mental well-being was closely monitored and supported during escalating behavior.
The facility failed to document and monitor behavioral symptoms as ordered and care planned for two residents with identified behavioral health needs. One resident with dementia and bipolar disorder had a physician’s order and care plan requiring shift‑by‑shift monitoring of specific behaviors, yet no behaviors were recorded on the MAR during the month in which the resident struck another resident, and no behavior note was entered in the clinical record for that incident. Another cognitively intact resident with a personality disorder had an order to monitor and track multiple behaviors and implement specific interventions, but when the resident became curt and then screamed and yelled at an LPN about medication, no behavior was documented on the MAR/TAR and no interventions were recorded in the clinical record. These failures occurred despite facility policy requiring nursing to monitor and document target behaviors daily and to use MAR documentation to trigger progress notes.
A resident with schizophrenia, dementia, depression, anxiety, HIV, alcohol abuse, and a history of verbal and physical aggression exhibited escalating behaviors, including unprovoked verbal abuse and striking staff and another resident, leading to multiple hospital and psychiatric evaluations. Despite physician orders for 15‑minute safety checks and a behavior care plan citing aggression toward staff and peers, the record lacked required safety check documentation over an extended period, and behavior interventions were not updated for many months despite repeated aggressive incidents. Staff interviews confirmed the resident’s unpredictable aggression, absence of effective de‑escalation techniques, and that ordered close monitoring was not consistently implemented after returns from behavioral health hospitalizations.
A resident with Alzheimer’s disease, dementia, anxiety, and schizophrenia was repeatedly observed with a strong urine odor in her room and in common areas, wearing the same ill-fitting, increasingly soiled clothing over several days, and hoarding paper towels without staff intervention. Records showed she had moderate cognitive impairment, occasional incontinence, and needed assistance with toileting and hygiene, yet her care plans, while listing multiple behavioral concerns and refusals of care, lacked individualized behavioral interventions. The resident’s guardian reported longstanding poor hygiene behaviors and stated the facility was not addressing them or communicating about behavioral health. Facility staff, including an LPN, a social services staff member, and the psychiatric NP, indicated that behaviors and refusals were not consistently documented or reported, and the NP was not advised of issues that might require intervention. No behavioral health program policy was provided when requested.
A resident with dementia, depression, anxiety, and a history of hallucinations had a violent behavioral outburst at the nurse’s station, verbally threatening to kill another resident, attempting to pull the other resident’s chair backward, and trying to grab the resident’s shirt. Staff separated the two residents, but then retreated into a nearby room without a window, leaving the aggressive resident alone and unmonitored at the nurse’s station, where he threw a drink, the phone, and attempted to throw the computer monitor. This occurred despite a care plan and a dementia aggression policy that called for ensuring safety and assessing the potential for harm to self or others.
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