Failure to Develop and Implement Comprehensive Care Plan for Resident with Behavioral Health and Medical Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the behavioral health and medical needs of a resident diagnosed with anxiety disorder, bipolar disorder, PTSD, and spinal stenosis. Despite multiple clinical assessments and documentation by the physician's assistant and psychologist noting the resident's mental health diagnoses, pain issues, and recent trauma from the loss of a family member, there were no care plan interventions created or revised to address these specific needs. The resident was prescribed medications for anxiety, depression, and pain, but the care plan did not reflect interventions for managing anxiety related to outside stressors, PTSD, grief, or paranoid and anxious behaviors. Further review revealed that the resident experienced episodes of lethargy, unsteadiness, and was found to have used marijuana via a vape pen, which was against facility policy. The resident's medications for anxiety and pain were held due to concerns about the effects of combining them with marijuana use. Despite the psychologist discussing relaxation techniques with the resident, there was no documentation of what these techniques were or their inclusion in the care plan. Interviews with staff confirmed that no person-centered care plan interventions were implemented to address the resident's medical, mental, and psychosocial needs.