Failure to Revise Behavioral Health Care Plan
Penalty
Summary
St. John Neumann Center for Rehab & Healthcare was found to be non-compliant with the requirements for comprehensive care plans as outlined in 42 CFR Part 483. The facility failed to review and revise the behavioral health care plan for a resident who was cognitively impaired and had multiple diagnoses, including dementia, anxiety disorder, depression, and manic depression. The resident was receiving antipsychotic medication routinely but had a history of refusing medications and care, which was not adequately addressed in the care plan. Despite multiple incidents of agitation, confusion, and physical altercations with a roommate, the care plan was not updated to reflect these behaviors or the resident's refusal of medications. The resident's clinical records revealed several instances where the resident expressed dissatisfaction with the facility, refused medications, and exhibited aggressive behavior. Notably, the resident was involved in physical altercations and expressed a desire to die, yet the care plan lacked documentation of any revisions to address these significant behavioral issues. The facility's failure to update the care plan in response to these events was a key factor in the deficiency identified during the survey.
Plan Of Correction
1. Facility conducted a thorough review of the resident, and updated CP to reflect refusals of care and/or medicine. 2. Using the PCC dashboard alerts, the Director of Nursing, and/or designee, will review the resident behaviors and/or refusal of care in the past 30 days and update the behavior care plans of residents that refuse care and/or medicine. 3. Education provided for facility IDT on requirement to update care plan with behaviors. 4. Using the PCC dashboard alerts, audits will be conducted weekly for 4 weeks then monthly for 2 months for any residents who have refusal behaviors and assure interventions are initiated/updated in Care Plans. 5. Results of these audits will be reported and reviewed with the Quality Assurance Performance Improvement Committee to ensure ongoing compliance.