Failure to Revise Care Plan After Behavioral Health Readmission
Penalty
Summary
The facility failed to review and revise the comprehensive care plan (CCP) for a resident following her readmission from a behavioral health unit (BHU). The facility's policy required that the CCP be reviewed and updated by the interdisciplinary team (IDT) after each comprehensive and quarterly Minimum Data Set (MDS) assessment, as well as after significant changes in the resident's condition. Despite this, the care plan for the resident, who had diagnoses including generalized anxiety disorder, schizophrenia, and depression, was not updated to reflect her recent behavioral health episode and subsequent readmission. The resident had a history of behavioral symptoms, including resisting care, urinating on the floor, and sitting on the floor, which were documented in her initial care plan. However, in the period leading up to her transfer to the BHU, she exhibited escalating behaviors such as paranoia, hallucinations, threats to staff and her roommate, and requests for police intervention. Nursing progress notes documented these behaviors, as well as the facility's actions to reassure her and eventually arrange for her transfer to the BHU for medical stabilization due to hallucinations, delusions, and threatening behavior. Upon her return from the BHU, the facility did not revise the resident's care plan to include her recent behaviors, updated diagnoses, or recommendations from the behavioral health stay. Interviews with the DON and Administrator confirmed that the expectation was for care plans to be reviewed and revised after hospital stays and to reflect all current and historical behaviors, but this was not done in this case.