Failure to Develop Comprehensive Care Plan for Insomnia and Medication
Penalty
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 personal history of other mental and behavioral disorders. The resident had a physician's order for trazodone to be administered at bedtime for insomnia, but the care plan did not address the resident's sleep issues or the use of trazodone. During interviews and record reviews, both a licensed nurse and the Director of Nursing confirmed that there was no specific care plan developed for the resident's sleep or insomnia. The facility's policy requires that a comprehensive care plan with measurable objectives and timetables be developed and implemented for each resident to address their physical, psychosocial, and functional needs. Despite this policy, the care plan for the resident in question did not include interventions for insomnia or the newly ordered medication, resulting in a failure to meet regulatory requirements for comprehensive care planning.
Plan Of Correction
Plan to Monitor Performance: 1. Medical Records will audit each resident for complete care plans after admission, when new orders are received, and quarterly to ensure completeness. Any missing care plans will be provided to staff to correct. A record of the audits will be provided to the DON to review and present to the quarterly QA committee. If needed, further corrective action will be created and implemented. All corrective action will be completed by 5/26/25. F 656