Incomplete Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop a complete, individualized, and comprehensive care plan for one resident. The resident was admitted with diagnoses including paranoid schizophrenia and insomnia, and was noted to be cognitively intact and able to ambulate independently. The resident's Behavior Care Plan identified a risk of inappropriate social behavior, specifically touching or scratching himself in common areas. However, the care plan did not include a goal or specify interventions to address this behavior. During interviews and record reviews, both the Acting Director of Nursing and the Program Director confirmed that the care plan was incomplete. They acknowledged that without a comprehensive care plan, staff would not be informed about the necessary interventions or goals for the resident. The facility's policy required that care plans include measurable objectives and timetables to meet residents' needs, but this was not followed in this case.