**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide appropriate assessment and treatment related to mental health concerns for 1 of 3 residents, Resident #2, experiencing symptoms of confusion and anxiety. This resulted in Resident #2 experiencing repeated and worsening episodes of behavioral distress from September 15, 2022, until October 10, 2022. Findings include: Review of Resident #2's records revealed the resident was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies (abnormal deposits of a protein in the brain affecting brain changes, in turn, which can lead to problems with thinking, movement, behavior, and mood), Parkinson's disease, anxiety disorder, depression, hypothyroidism, and gastroesophageal reflux disease. Review of Resident #2's physician orders dated 09/15/22 documented, consult psychiatry services as needed. During an interview on 11/17/22 at 2:12 PM the Director of Nursing (DON) stated, He [Resident #2] has Lewy body and Parkinson's. He had some delusions [false beliefs] and hallucination [seeing or hearing things that others do not see or hear] from the Parkinson's. She [Resident #2's spouse] was resistant to medications wanted a natural approach. Upon admission, they signed a consent to psych [psychiatric] services in case it was needed due to his history. Review of Resident #2's Minimum Data Set Comprehensive assessment dated [DATE], documented behaviors including hallucinations, other behavioral symptoms not directed at others, and wandering 4 to 6 days out of the 7-day observation period. Changes in behavior were documented as worse. Review of Resident #2's progress notes documented the following: Behavior note dated 9/15/22 at 5:59 PM read, resident became anxious saying goodnight to spouse wandering around court exit seeking hard to redirect. Behavior note dated 9/16/22 at 5:57 PM read, resident becoming more anxious and wandering aimlessly . going into others' rooms and rummaging through others' belongings. He is not easily redirected. Behavior note dated 9/18/22 at 6:44 AM read, resident ambulating around court . agitated, restless. Ambulating at a fast pace. Resident would come to the med [medication] cart, and staying closely behind this writer, limiting movement, then resident would reach into drawers on the med cart. Behavior noted dated 9/18/22 at 1:07 PM read, resident continues to be anxious and exit seeking . he has been behind nurse's desk trying to go through the plastic bins, he was redirected, but it doesn't last for long, not making sense when he talk [sic]. [Advanced Registered Nurse Practitioner's name] was notified and gave orders to give stat [immediately] Ativan [an antianxiety medication] 0.5 milligram (mg) now and then start Ativan 0.5 every eight hours as needed for anxiety and agitation. Wife was notified of behaviors and new order and gave consent to give medication. Behavior note dated 9/18/22 at 11:11 PM read, resident has been agitated and restless since shift began. Has been redirected away from med carts numerous times . placing his hands inside drawers, touching the computer, etc. [sic]. Went into a room down 300 hall and was discovered partially clothed trying to do something to one of the beds. Resident was standing in front of a table, that had been placed in front of the window in 300 hall music room. Staff saw resident pick table up from the floor and was able to take table away from resident before he threw it through the window. PRN [Pro Re Nata - as needed] Ativan 0.5 mg given at that time (10:30 PM) for agitation/restlessness. Behavior note dated 9/19/22 at 9:54 AM read, resident pacing about court looking for car, hard to redirect. Nurse observed resident opening windows several times this AM. Nursing note dated 9/19/22 at 4:10 PM read, new order received for Lorazepam [an antianxiety medication] 0.5 mg TID [three times a day] spouse notified. Behavior note dated 9/20/22 at 6:45 PM read, resident restless, pacing at frequent intervals, turning over chairs, removing items from med cart, removing fall decorations from countertops, going in and out of resident rooms, not easily redirected. Resident went on patio climbed brick wall, noted shaking wooden wall, not easily [redirected]. Resident urinated on floor, went in another resident room, and removed all of his clothing, not easily redirected. Behavior note dated 9/21/22 at 7:15 AM read, resident was pacing the common areas and moving furniture, trying to reach behind the nurses' station to grab items. Resident also was redirected from trying to enter other resident's rooms. He was disrobing walking down the halls. Social Service note dated 9/21/22 at 1:08 PM read, [Resident #2'name] is a new admit GSC [Good Samaritan Center]. He is here for LTC [long term care] and wife does not want d/c [discharge] planning discussed with resident nor herself. Resident is on secured memory care unit d/t [due to] his wandering and elopement risk. He has poor safety awareness. He is very impulsive, haphazard, and quick. He is active and high functioning with activities and needs a lot of things to keep him occupied. Behavior note dated 9/22/22 at 11:37 PM read, resident out in common area at start of shift. Resident invading others privacy. Trying to touch some of the female residents and causing them to get agitated and yell at him. During an interview on 11/17/22 at approximately 2:30 PM Staff F, Licensed Practical Nurse (LPN) stated, [Resident #2's name] didn't touch any of the female residents. He was attempting to approach them to touch them, and we intervened and prevented his attempts to touch them. He would have his hand out as he was approaching like he was going to touch them and this agitated the other residents and they would yell at him to stay away from them. Behavior note dated 9/23/22 at 9:15 PM read, resident came up to this writer and stated, How can you stand it here with all the evil spirits walking around. Asked resident what he meant, and he continued to state he sees evil spirits everywhere and that he doesn't see them all the time, but he sees them right now. Resident redirected. Behavior note dated 9/25/22 at 6:30 PM read, Resident calm this am Wife present through Lunch, later in day Resident restless, pacing at frequent intervals, moving furniture in Common area and in his room. CNA reported finding window in Resident's room off track with access to screen. Maintenance notified and window repaired. Resident made no noted attempt to go through window. Behavior note dated 10/2/22 at 11:36 PM read, Anxious tonight. Observed [resident] over the brick wall at start of shift easily redirected inside. Redirected out of other's rooms several times. Resident moving and lifting up furniture. Behavior note dated 10/6/22 at 1:35 AM read, resident was agitated all evening until staff assisted him to bed. Resident turning over furniture, taking his shirt off. Holding on to other residents. Trying to jump over wall into nursing station. Resident not easily redirected. Behavior note dated 10/7/22 at 6:15 AM read, resident up this morning pacing hallway. Agitated. Redirected numerous times out of female rooms. Resident yelled at this writer that was a bunch of bull that I tell him all the rooms are female. Resident going from door to door shaking the handles. Resident knocking over furniture trying to go out to the patio. This writer sat in a chair by patio and resident told me I was in on the scam involving drugs and money and I was going to regret it. Redirection unsuccessful. Resident grabbed the back of the chair and flipped it over with this writer sitting in it. As I was trying to get up off the floor, resident bolted through patio door and jumped the brick wall. This writer went out to try and get resident in due to it being cold and dark. Resident picked up a wind chime and threw it at me. Resident pacing around brick wall shaking white fence. Other staff came to help, and resident jumped on the brick wall and was halfway over white fence. We grabbed his legs, and he jumped back down. Resident continues delusional [sic]. Grabbed a shepherd's hook [previously holding wind chime] and started hitting the windows of 100 hall rooms. After several redirections, resident through [sic] the shepherd's hook. Resident continues to try and get over white fence with staff continually asking him to get down and come inside. Resident continues to talk about drugs and money and how we are in on it. Male staff came to patio to assist. Resident did not have any change in behavior. Resident picked up lattice and propped it up on the white fence and attempted to climb up it, but it broke. Resident picked up another wind chime and threw it on the roof. Resident kept grabbing this writer's arm and telling me to go. Nursing note dated 10/7/22 at 3:23 PM read, provider [Staff B's name] notified of residents increased behaviors. New orders to start Seroquel 0.25 mg at 12:00 PM in addition to his 8:00 PM dose wife aware. Behavior note dated 10/7/22 at 5:20 PM read, Resident was asleep at beginning of the shift in common area. He was cooperative with med administration and consumed breakfast of 100%. As the day went by he became more active, pacing the court in and out of resident's rooms, and has plundered through others belongings, difficult to divert his attention. This behavior usually occurs after wife has left from visiting and if he happens to verbally mention her to staff that's when he becomes anxious. Behavior note dated 10/7/2022 at 5:30 PM read, Resident continues to search for his wife after she left about an hour ago, staff reassured him that she would return first thing in the morning. Resident then began calm down as stopped pacing and searching for his wife. Resident did mention earlier that the women here are stealing money and that he did not trust people who stold [sic] his money. Once again verbal reassurance given that there are no theifs [sic] here at G.S.C. Nursing note dated 10/08/22 at 6:45 PM read, resident restless in AM, pacing hall at frequent intervals, later less restless. Resident refused 2:00 PM Ativan, denies dizziness states I don't want to take it anymore. Wife reported resident having hallucinations. Resident restless in evening, moving tables, taking down decorations, easily redirected, but requires frequent redirection. Elopement note dated 10/9/22 at 6:44 AM read, This writer was informed by the [200 hall nurse's name] via phone at 3:48 AM on 10/9/22 that resident was combative, agitated and physically aggressive. [200 hall nurse's name] said she could not get through to switchboard to call the on-call provider. Then this writer received another phone call from [200 hall nurse's name] that the resident broke a window, and he eloped through the broken window, and that she just called 911. An interview was attempted on 11/17/22 at approximately 1:28 PM with Staff B, CNA via telephone for clarification of behaviors experienced and resistance to redirection for Resident #1. A message was left, and no return call was received. An interview was attempted on 11/17/22 at approximately 1:28 PM with Staff C, CNA via telephone for clarification of behaviors experienced and resistance to redirection for Resident #1. A message was left, and no return call was received. Review of the documentation provided by the facility on 11/17/22 showed [Name of Psychology Service Provider] onsite visits to Good Samaritan Center conducted by Staff A, ARNP (Advanced Registered Nurse Practitioner), providing services to residents on 9/20/22 and 10/4/22. During an interview on 11/17/22 at 2:12 PM, the Director of Nursing confirmed Resident #2 was on the list to be seen by psychology services but was not seen prior to the elopement. During an interview on 11/17/22 at 3:41 PM, the Medical Director/Resident #2's attending physician stated, He [Resident #2] was very dependent on being with his wife. He is a retired mechanic and likes to take apart things, like the air conditioner. He had a lot of high anxiety and had eloped from his house. We did not know that he was disturbed as much as he was. When he started getting more aggressive, we were looking at his medications. I would have expected him to be seen on one of those occasions when [Name of Psychological Service Provider] was in the building prior to the elopement. Review of the medical services agreement between [Name of Psychology Service Provider] doing business as (dba) [Name of Psychology Service Provider] and the facility dba Good Samaritan Center dated 4/1/22 read, Facility hereby engages [Name of Psychology Service Provider] to provide the following services to its patients . psychiatry and psychology services. [Name of Psychology Service Provider] will provide engaged services to facility's patients on a weekly, biweekly, or monthly basis depending on the need of the facility which will be a mutually decided between [Name of Psychology Service Provider] and facility. The agreement was signed by the facility Administrator on 4/12/22 and by [Name of Psychology Service Provider] medical director on 4/1/22. Review of facility's assessment tool Section 1.3. read, Indicate if you may accept residents with, or your residence may develop, the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. Table 2: Common diseases, conditions, physical and cognitive disabilities. Category. Psychiatric/Mood disorders. Psychosis (hallucinations, delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder, Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. Section VII. Part 2: Services and care we offer based on our resident's needs. Table 4. Mental Health and Behavior. Manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD (post-traumatic stress disorder), other psychiatric diagnosis, intellectual or developmental disabilities. Psychiatrist sees patients in the facility each month and is available for phone consultation 24/7. Review of the facility's policy titled Behavioral Health Services with a revised date of February 2019 read, Policy Statement. 1. The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Policy Interpretation and Implementation. 2. Residents who exhibit signs of emotional psychosocial distress receive services and support that address their individual needs and goals for care.