Failure to Include Depression in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan that addressed all of a resident's identified needs. Specifically, a resident with diagnoses including schizoaffective disorder, major depressive disorder, and dementia did not have depression listed as a focus area in her comprehensive care plan, despite this diagnosis being documented in her medical record and assessment. The resident's Minimum Data Set (MDS) indicated active depression, and the psychiatric nurse practitioner's note also addressed major depressive disorder as a primary diagnosis. Interviews with facility staff, including the MDS LVN, Regional Care Manager, and Administrator, confirmed that depression was omitted from the care plan and acknowledged that it should have been included, regardless of whether the resident was receiving medication for the condition. The facility's policy requires that all identified needs from the comprehensive assessment be included in the care plan with measurable objectives and timeframes, but this was not followed in the case of this resident.