Failure to Develop and Implement Behavioral Health Care Plan for Resident with Anxiety
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's hospital-diagnosed anxiety, did not monitor behavioral symptoms, and did not provide necessary behavioral health services. Despite documentation from the hospital discharge summary, physician assessments, and therapy evaluations all identifying anxiety as an active medical condition, the facility did not code anxiety as an active diagnosis in the medical record until several days after admission. The baseline care plan created at admission did not include any focus, goals, or interventions related to anxiety, and there was no evidence of individualized behavioral health interventions being developed or implemented. Throughout the resident's stay, multiple instances of care refusal, verbal aggression, and behavioral symptoms such as yelling and use of abusive language were documented. Staff, including therapy and nursing, observed and reported these behaviors, but there was no documented evidence that these symptoms were addressed through the care planning process or that the interdisciplinary team (IDT) discussed or intervened regarding the resident's anxiety prior to the resident expressing suicidal ideation. The resident also reported to surveyors feelings of depression, hopelessness, and ongoing suicidal thoughts, and stated that requests for medication to address anxiety and sleep issues were denied by staff. Interviews with staff confirmed that the resident's behavioral symptoms and refusals were recognized but not addressed through a care plan or IDT intervention. The facility's own policy required assessment and individualized care planning for behavioral health symptoms, but this was not followed. The lack of timely recognition, documentation, and intervention for the resident's anxiety and behavioral health needs resulted in psychosocial harm, as evidenced by the resident's reported suicidal ideation.