Failure to Address PTSD and Develop Care Plan After Elevator Incident
Summary
The facility failed to develop a plan of care for a resident diagnosed with PTSD, anxiety, and depression, following a distressing incident where the resident was trapped in an elevator. The resident, who had a history of PTSD, hypertension, depression, and a nonhealing diabetic foot ulcer, experienced a traumatic event when the elevator malfunctioned, causing severe anxiety and triggering PTSD symptoms. Despite the resident's request for psychological support, there was no documented evidence that the facility informed the physician or therapist about the incident or the resident's request for therapy. Interviews with staff confirmed the resident's distress and the lack of immediate psychological intervention. The Nursing Home Administrator was aware of issues with the elevator prior to the incident but did not take action to shut it down until after the resident was trapped. The facility's failure to address the resident's mental health needs and the lack of a care plan for the resident's PTSD and related conditions contributed to the deficiency.
Plan Of Correction
1. Resident R220 was seen by psychological services. 2. Residents with PTSD will be seen by psychological services to ensure proper plan is in place. 3. Staff will be educated on the components of this regulation with an emphasis on managing behavioral difficulties appropriately. 4. Audits of 5 residents with PTSD will ensure they have been seen by psychiatric services 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a history of depression and anxiety experienced increased distress due to constant yelling from other residents. Despite reporting frustrations, the facility failed to address the issue, leading to the resident's decreased social interaction and increased withdrawn and angry behaviors. Incomplete mood assessments and ineffective interventions contributed to the deficiency.
A resident with severe cognitive impairment exhibited ongoing verbal, physical, and sexually inappropriate behaviors, including aggression and refusal of care. Despite repeated documentation of these behaviors, staff did not assess or analyze the situation or attempt new interventions, and no psychiatric evaluation was scheduled, as confirmed by the DON.
A resident with rheumatoid arthritis and muscle weakness expressed multiple grievances, including medication issues and lack of showers, but did not receive necessary behavioral health services. Despite documented concerns and a desire to return home, the facility failed to follow up with social services. Staff interviews revealed a lack of adherence to reporting and documentation processes, highlighting deficiencies in addressing the resident's needs.
A resident with Parkinson's and dementia was inappropriately placed in a secured unit without proper clinical indication or authorization, leading to distress and an elopement incident. Despite being cognitively intact, the resident was confined based on verbal communication and assumptions, rather than documented evidence. The facility failed to secure the environment, allowing the resident to exit through a window, highlighting lapses in safety and communication.
The facility failed to follow care-planned interventions for a resident with attention-seeking behaviors, resulting in an incident where one resident hit another. Additionally, the facility did not evaluate or address the safety concerns of a resident who felt unsafe after a resident-to-resident incident.
A facility failed to address a resident's behavior of removing her feet from wheelchair footrests, leading to Immediate Jeopardy when a nurse aide repeatedly grabbed the resident's ankles, causing distress and resulting in physical and verbal altercations.
Failure to Address Resident's Psychosocial Distress Due to Environmental Noise
Penalty
Summary
The facility failed to adequately assess and address a resident's expressions of distress, leading to decreased social interaction and increased withdrawn, angry, and depressive behaviors. The resident, a cognitively intact female with a history of major depression and anxiety disorder, expressed frustration due to the constant yelling of other residents in her hall. Despite reporting these frustrations to staff, no effective measures were taken to alleviate the situation, resulting in the resident's increased distress and uncharacteristic behavior. Observations revealed that the resident preferred to keep her door closed and use ear buds to block out the noise, yet she continued to experience frustration and anxiety. The facility's psychiatric consults noted the resident's sleep disturbances and recommended non-pharmaceutical interventions, but these were not effectively implemented. The resident's mood assessments were incomplete, further indicating a lack of comprehensive evaluation and intervention by the facility. Interviews with staff confirmed that the issue of residents yelling was well-known, yet no grievance forms were completed, and the problem persisted. The facility's decision to place several residents who frequently yelled in the same area exacerbated the situation, affecting the resident's mental well-being. The Social Service Director acknowledged the resident's recent behavioral changes, which were uncharacteristic and linked to the ongoing disturbances.
Plan Of Correction
Element 1: Resident 52 no longer resides in facility. Element 2: Residents on C hall with a Brief Interview of Mental Status of 9 or greater had a Patient Health Questionnaire-9 completed to ensure residents have had no expressions of distress, developed decreased social interaction, increased withdrawal, anger, and depressive behaviors. Any changes in Patient Health Questionnaire-9 have had referrals made to psychology services. Element 3: CNAs and Nurses were re-educated on proper documentation of behaviors including depression, agitation, withdrawal, distress, anger, etc. Interdisciplinary Team will review clinical documentation M-F to ensure any changes in behaviors are followed up on. Element 4: The Administrator will complete an audit reviewing 6 residents per week to evaluate Patient Health Questionnaire-9 scores and ensure appropriate interventions are in place if eligible. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.
Failure to Assess and Intervene for Escalating Resident Behaviors
Penalty
Summary
The facility failed to monitor, assess, and analyze a resident's escalating behavioral issues, including verbal and physical aggression as well as inappropriate sexual behaviors. The resident, who was severely cognitively impaired and required staff assistance for daily care, exhibited a pattern of combative and aggressive actions, such as refusing care and medications, yelling at staff, threatening to hit staff, wandering into other residents' rooms, and making inappropriate sexual comments. These behaviors were documented repeatedly in nursing notes over a two-month period. Despite the ongoing and increasing nature of these behaviors, there was no documented evidence that the facility assessed or analyzed the resident's behaviors or attempted new interventions to address them. Additionally, although the resident's antipsychotic medication was discontinued and later restarted, no psychiatric evaluation or treatment was scheduled. The Director of Nursing confirmed that the resident was in need of psychiatric evaluation, but none had been arranged as of the time of the survey.
Failure to Provide Behavioral Health Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health services despite the resident expressing multiple concerns and grievances. The resident, who was admitted with diagnoses including rheumatoid arthritis and muscle weakness, had a BIMS score indicating no cognitive impairment. Despite being described as pleasant and cooperative, the resident reported issues such as not receiving the correct medication, not having a shower since admission, and feeling frustrated and distrustful of the aides. These concerns were documented in various progress notes, yet there was no evidence of a referral for behavioral health or social services. The resident expressed a desire to return home, citing dissatisfaction with the care received, including issues with medication and therapy. The resident also reported feeling upset about the lack of attention from staff, such as an aide being on the phone during meal service. Additionally, the resident was worried about housing issues and the potential theft of a walker. Despite these documented grievances, the facility did not follow up with social services or behavioral health services to address the resident's concerns. Interviews with facility staff revealed a lack of action in response to the resident's grievances. Staff members described processes for reporting abuse and psychological impacts of isolation, but there was no indication that these processes were followed in this case. The facility's policies on abuse, neglect, and promoting resident dignity were not adhered to, as there was no documentation of interviews or care plan revisions. The medical director acknowledged the need for better documentation and follow-up on complaints, indicating a gap in the facility's response to the resident's needs.
Inappropriate Secured Unit Placement and Lack of Proper Documentation
Penalty
Summary
The facility failed to ensure appropriate placement and interventions for a resident, leading to a deficiency in behavioral health services. The resident, who had Parkinson's Disease and dementia with agitation, was admitted to the facility for therapy and strengthening. Despite being cognitively intact and having a BIMS score of 14, the resident was placed in a secured unit without a clear clinical indication or proper authorization. This decision was based on verbal communication and assumptions rather than documented evidence or a formal order from the attending physician. The resident expressed frustration and confusion about being in the secured unit, which was not aligned with his cognitive status and personal capabilities. He was able to manage his finances and expressed a desire to leave the facility, indicating that he did not belong in the secured unit. The resident's family and physician were not adequately consulted about the placement, and there was a lack of proper documentation to justify the decision. The facility's staff, including the DON and LPN, acknowledged that the resident was independent and did not require the restrictions of a secured unit. The deficiency was further compounded by the facility's failure to secure the resident's environment properly. The resident was able to exit the facility through a window due to loose metal brackets, highlighting a lapse in safety measures. Interviews with staff revealed confusion and miscommunication regarding the resident's placement and the necessity of the secured unit. The facility's policy required a signed consent for secured unit placement, which was not appropriately obtained or documented, leading to the resident's inappropriate confinement and subsequent distress.
Failure to Implement Care-Planned Interventions and Address Resident Safety Concerns
Penalty
Summary
The facility failed to ensure that a resident did not display increased angry and aggressive behaviors by not following care-planned interventions. Specifically, Resident 6, who had attention-seeking behaviors towards males, hit another resident (Resident 1) with a back scratcher after the latter wandered into her room. The care plan for Resident 6 included placing a stop sign across her door to prevent such incidents, but there was no documented evidence that this intervention was implemented. The Director of Nursing confirmed the absence of the stop sign, which contributed to the incident where Resident 6 hit Resident 1, who had Alzheimer's disease and dementia and exhibited wandering behaviors. This failure resulted in Resident 1 being hit on the wrist, although no injury was reported for Resident 6. Additionally, the facility failed to evaluate and address the fear and safety concerns of Resident 7 after a resident-to-resident incident. Resident 7, who was cognitively intact, reported that Resident 4 entered her room through the bathroom and grabbed her wrists, causing a bruise and discomfort. Despite a stop sign being placed on the bathroom door, Resident 4 continued to enter Resident 7's room, leading to ongoing fear and a lack of safety for Resident 7. The Director of Nursing confirmed that there was no documented evidence of an assessment to address Resident 7's fear and safety concerns following these incidents.
Failure to Address Resident's Behavioral Needs
Penalty
Summary
The facility failed to properly address a resident's behavior of repeatedly taking her feet off the wheelchair footrests and placing them on the ground. This resulted in Immediate Jeopardy when a nurse aide continued to grab hold of the resident's ankles, causing her to yell out and place her feet back on the ground. The resident then hit the nurse aide, who responded by slapping the resident's hand and calling her an offensive name. The resident involved had diagnoses including Parkinson's disease, anxiety, and depression. Despite the resident's clear distress and refusal to keep her feet on the footrests, the nurse aide persisted in trying to place the resident's feet back on the footrests. This escalated the situation, leading to physical and verbal altercations between the resident and the nurse aide. There was no documented evidence in the resident's clinical record indicating that the nurse aide attempted different approaches or interventions to prevent the behavior from escalating. The facility's policy on behaviors, which includes various non-pharmacological interventions, was not followed in this instance, leading to the deficiency.
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.
