Failure to Develop and Implement Person-Centered Baseline Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive baseline care plan for a newly admitted resident with complex behavioral and mental health needs. Upon admission, the resident had diagnoses including COPD, vascular dementia with behavioral disturbances and agitation, PTSD, anxiety, and impulse disorder, and was known to exhibit confusion, mood swings, aggression, and wandering. The baseline care plan completed two days after admission lacked specific information and interventions regarding the resident's mental health and behavioral concerns, despite these being checked as areas of need. No individualized instructions, triggers, or interventions were documented for the resident's PTSD, impulse disorder, or dementia-related behaviors. Subsequent progress notes documented incidents of verbal and physical aggression, including an episode where the resident became aggressive after being denied a smoke break, resulting in police and EMS involvement and temporary transfer to the hospital for psychiatric evaluation. Interviews with LPNs confirmed that the baseline care plan was incomplete and did not provide necessary guidance for staff regarding the resident's mental health and behavioral needs. Facility policy required that baseline care plans include person-centered instructions and interventions based on the resident's diagnoses and needs, which was not met in this case.