Failure to Develop Comprehensive Care Plan for Behavioral Health Needs
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan to address a resident's behaviors related to bipolar disorder and depression. Despite the resident having documented diagnoses of hemiplegia, seizures, mood disorder, and depression, and being prescribed medications such as Lexapro and Risperidone for these conditions, the care plans did not include specific interventions or monitoring related to these behavioral health needs. The resident's Minimum Data Set and psychiatric examination confirmed the presence of depression and mood disorder, yet these were not reflected in the active care plans. During interviews and record reviews, the DON acknowledged that the care plans lacked specific focus on the resident's depression, bipolar disorder, and the use of related medications. The facility's own policy and procedure required care plans to incorporate all problem areas identified through comprehensive assessment and to be revised as the resident's condition changed. The absence of these care plan elements meant that the facility could not effectively track or manage the resident's behavioral health conditions.