Failure to Develop and Implement Comprehensive Care Plan for Resident with Behavioral and Medication Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex diagnoses, including schizophrenia, mood affective disorder, and epilepsy. Despite the resident's admission with significant mental health needs and moderate cognitive impairment, there were no care plans created to address the use of Clozapine and Ativan, both prescribed for behavioral and mood management. Additionally, after a documented change of condition involving increased agitation and restlessness, which resulted in the resident striking out at staff and attempting to get out of bed unassisted, the facility did not update or create a care plan to address these behavioral changes or the new medication order for Ativan. Interviews and record reviews confirmed that the Director of Nursing acknowledged the requirement for comprehensive care plans following medication changes or changes in condition, as outlined in the facility's own policy. However, no such care plans were developed for the resident's behavioral manifestations, use of psychotropic medications, or monitoring needs. The absence of these care plans was confirmed by the DON, who stated that this omission could result in staff missing necessary interventions and failing to adequately address the resident's needs.