Health inspection·November 25, 2024

F740 §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. Title 22 §72311 Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/28/2024, an unannounced visit was conducted at the facility during the annual Recertification survey. The facility failed to ensure Resident 39, who had a diagnosis of major depressive disorder (a common and serious medical illness, with severe low mood, sadness and despair) was provided necessary behavioral health care. The facility failed to: 1. Monitor Resident 39 for signs and symptoms of sad feelings and depression, per the Mood Problem with Crying Episodes Care Plan initiated 9/9/2022. 2. Provide Resident 39 with a psychiatrist or psychologist to evaluate and assess the resident's mood. 3. Evaluate the effectiveness of the care plan for Resident 39's depressive symptoms. 4. Implement the facility's policy and procedure titled, "Behavioral Assessment, Intervention and Monitoring," dated 8/30/2024, to provide behavioral health services and identify, document, and inform the physician about specific changes in the resident's mental status, behavior, and cognition. As a result, on 10/28/2024, Resident 39, a 53-year-old male, expressed feelings of frustration since the last comprehensive assessments on 12/1/2023 and 2/29/2024 and began to cry with tears streaming down his face. A review of Residents 39's admission record indicated the resident was admitted to the facility on 2/27/2021, with diagnoses including nontraumatic intracerebral hemorrhage (a type of stroke that occurs when a pool of clotted blood forms in the brain tissue), major depressive disorder (a common and serious medical illness, severe low mood, sadness and despair), hemiplegia (loss of the ability to move one side of the body), hemiparesis (weakness on one side of the body), abnormalities in gait and mobility. A review of Resident 39's Mood Problem Care Plan initiated 3/10/2021, manifested by feeling down, trouble sleeping, and feeling bad, indicated the interventions were to encourage Resident 39 to verbalize feelings and offer understanding. The Mood Problem Care Plan did not indicate an intervention to monitor the resident for adverse signs and symptoms. In addition, upon request the care plan was not updated, reviewed, or revised quarterly, as there were no current dates to reflect the review. A review of Resident 39's Mood Problem with Crying Episodes Care Plan initiated 9/9/2022, with psychologist visits every three weeks indicated the interventions were to monitor / record / report to MD as needed acute episodes of sad feelings, sign and symptoms of depression, and monitor for feelings of worthlessness or guilt. A review of Resident 39's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/1/2023, indicated the resident presented with feeling down, depressed, or hopeless for 2-6 days. Resident 39's functional abilities and goals indicated the resident used a wheelchair, was dependent on staff assistance for oral hygiene and toileting hygiene. The MDS indicated Resident 39 did not attempt or perform the ability to walk. A review of Resident 39's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 2/29/2024, indicated the resident presented with feeling down, depressed, or hopeless for 2-6 days. Resident 39's functional abilities and goals indicated the resident used a wheelchair, was dependent on staff assistance for oral hygiene and toileting hygiene. The MDS indicated Resident 39 did not attempt or perform the ability to walk. According to a review of Resident 39's CSC - PHQ 2 to 9 Evaluation (a self-report patient health questionnaire, social services trauma assessment, tool used to gauge the resident's level of depression) dated 10/21/24, the resident felt down, depressed, or hopeless 12-14 days (nearly every day). During an interview on 10/28/2024 at 11:05 AM, the SSD stated in her opinion the PHQ questions did not reflect how depressed Resident 39 may be. For example, the SSD stated, she performed an interview with Resident 39 using the CSC -PHQ assessment, the questions asked did not reflect how depressed the resident really appeared. During a concurrent observation and interview on 10/28/2024 at 11:15 AM, Resident 39 was in his room, lying in the bed, and the call light was noted within reach. Resident 39 stated he did not like the care he received, and that the facility was not doing enough to provide the assistance he needed to get better. Resident 39 stated he did not know what was needed to get better and started to cry. Resident 39 was observed laying on his right side and began an expressionless cry with tears coming down his face. During an interview on 10/30/2024 at 12:49 PM Certified Nurse Assistant (CNA) 3 stated Resident 39 expressed feeling down and sad to the nursing staff in the past. CNA 3 stated she had observed Resident 39 cry about feeling down in the past and that the nurses were aware. CNA 3 stated when the resident expressed those feelings, CNA 3 tried to get Resident 39 to smile and focus on something happy. A review of Resident 39's clinical record indicated there was no monitoring / recording / reporting to MD as needed of acute episodes of sad feelings, sign and symptoms of depression, or monitor for feelings of worthlessness or guilt, per Resident 39's care plan. A review of Resident 39's October Medication Administration Record (MAR) with Licensed Vocational Nurse (LVN) 1 indicated the resident was not being monitored for mood problem behavior or episodes sadness, hopelessness, or depression. LVN 1 entered the nurse's computer system to review Resident 39's monitoring which remained blank. During a concurrent interview on 10/30/2024 at 1:02 PM, LVN 1 stated Resident 39 was not being monitored for a mood problem. LVN 1 stated, "The resident did not appear down or depressed and did not have diagnoses of psychosis, aggressive behavior, or did not verbalize wanting to harm himself or others." During concurrent interview and record review on 10/30/2024 at 1:22 PM, with the Social Services Director (SSD), Resident 39's PHQ / trauma assessment by Social Services dated 10/21/24, was reviewed. The SSD stated the evaluation was performed 72 hours after admission, but if the resident had been at the facility for a while, and the trauma assessments were done quarterly (Resident 39's last PHQ trauma assessment was dated 5/2024). The SSD confirmed that Resident 39 was not being monitored for signs and symptoms of depression nor had a visit from a psychiatrist or psychologist. During a concurrent interview and record review on 11/1/2024 at 1:31 PM with the Director of Nursing (DON), Resident 39's CSC - PHQ Evaluation dated 10/21/2024 was reviewed. The DON stated the process to monitor a resident with behavioral issues begins with a psychologist or psychiatrist on staff who would place an order to monitor the resident. The DON stated a change of condition would be done to monitor per doctor's orders and psych evaluation. The DON stated the impact to the residents who were not monitored resulted in the resident's behavioral situation unmanaged. The DON stated the CSC - PHQ Evaluation occurred during the time when the new social services director was hired and the old was leaving. The protocol was the assessment should be communicated to nursing. The DON stated Resident 39 was not receiving medication for his depression diagnosis therefore he would not be monitored. The DON stated the facility is obligated to provide the needed care. A review of the facility's policy and procedure titled, "Behavioral Assessment, Intervention and Monitoring," dated 8/30/2024, indicated the facility would provide behavioral health services to maintain the highest practicable physical, mental, and psychosocial well-being. The policy indicated nursing staff would identify, document, and inform the physician about specific changes in the resident's mental status, behavior, and cognition. The policy indicated new onset or changes in behavior would be documented. The facility failed to ensure Resident 39, who had a diagnosis of major depressive disorder was provided necessary behavioral health care. The facility failed to: 1. Monitor Resident 39 for signs and symptoms of sad feelings and depression, per the Mood Problem with Crying Episodes Care Plan initiated 9/9/2022. 2. Provide Resident 39 with a psychiatrist or psychologist to evaluate and assess the resident's mood. 3. Evaluate the effectiveness of the care plan for Resident 39's depressive symptoms. 4. Implement the facility's policy and procedure titled, "Behavioral Assessment, Intervention and Monitoring," dated 8/30/2024, to provide behavioral health services and identify, document, and inform the physician about specific changes in the resident's mental status, behavior, and cognition. As a result, on 10/28/24, Resident 39 expressed feelings of frustration since the last comprehensive assessments on 12/1/2023 and 2/29/2024 and began to cry with tears streaming down his face. The above violation had direct or immediate relationship to the health, safety, or security of Resident 39.