Failure to Develop Care Plan for Insomnia and Trazodone Use
Penalty
Fine: $26,685
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident who was admitted with multiple diagnoses, including dementia, depression, anxiety, and a history of other mental and behavioral disorders. The resident had a physician's order for trazodone to be administered at bedtime for insomnia. Upon review of the resident's medical record and care plans, both a licensed nurse and the Director of Nursing confirmed that there was no specific care plan addressing the resident's sleep issues or insomnia, despite facility policy requiring measurable objectives and timetables to meet each resident's needs.