Failure to Develop Person-Centered Care Plan for Behavioral Health Needs
Penalty
Summary
A deficiency was identified when the facility failed to comprehensively assess and develop a person-centered care plan for a resident experiencing ongoing grief and sadness following the recent loss of her son, as well as past trauma. The resident, who has diagnoses including unspecified dementia, major depressive disorder, and other behavioral and emotional disorders, was found to be moderately cognitively impaired and had an activated power of attorney. Despite receiving behavioral health services and having a documented history of significant trauma and recent bereavement, the facility did not incorporate recommended interventions from behavioral health professionals into the resident's care plan. The resident's trauma screening assessment revealed a history of physical and sexual abuse, life-threatening illness, severe human suffering, and the sudden, unexpected death of someone close. A psychology appointment documented maladaptive behavioral symptoms, emotional distress, and specific recommendations for care, such as increasing positive emotions, integrating faith-based support, encouraging socialization, and providing validation during episodes of grief. However, these recommendations were not reflected in the resident's comprehensive care plan or Kardex, which only included general statements about encouraging activity participation and observational behavior monitoring. Interviews with facility staff, including the Nursing Home Administrator and Director of Social Services, confirmed that the recommended interventions from behavioral health were not care planned and that staff were not fully aware of the specifics of the resident's trauma. Observations showed the resident was tearful and withdrawn, and while she reported some support from nursing staff, the lack of a comprehensive, individualized care plan addressing her grief and trauma constituted a failure to provide necessary behavioral health care and services.