Failure to Update Care Plan for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect their current needs and required services. Specifically, a resident admitted with diagnoses including bipolar disorder and diabetes had a psychiatric consult that recommended monitoring and documentation of various behavioral and mood symptoms. However, the resident's comprehensive care plan, last revised after the psychiatric consult, did not include any assessment, goals, or interventions related to bipolar disorder or the monitoring of behavioral symptoms as recommended. A review of the facility's policy confirmed that care plans are required to address all identified medical, nursing, mental, and psychosocial needs. During an interview, the DON acknowledged that the care plan had not been updated to reflect the resident's current mental health status, associated risks, or necessary interventions. This deficiency was identified through clinical record review and staff interview.