Failure to Develop and Implement Comprehensive Behavioral Health Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the mental health and behavioral needs of a resident with a history of depression and Bipolar II disorder. Upon admission, the resident's records indicated diagnoses of stroke, depression, and Bipolar II disorder, as well as recent participation in multiple psychology appointments at a previous facility. The Minimum Data Set (MDS) assessment identified moderate cognitive impairment and mild depression, but these findings were not incorporated into a behavioral health care plan. Despite documented episodes of aggression, agitation, and suicidal ideation, there was no care plan in place to address the resident's mental health needs. The resident exhibited threatening behavior toward staff, self-harm, and made multiple statements about wanting to end his life. The facility's Social Services Director and Director of Nursing confirmed that no behavioral health care plan was developed, and the resident did not receive mental health appointments after admission. The Social Services Director also acknowledged being behind on developing the resident's plan of care. While under 1:1 monitoring due to suicidal ideation, the resident was able to initiate a physical altercation with another resident, resulting in harm. The lack of a comprehensive care plan addressing the resident's behavioral and mental health needs contributed to these incidents, as the facility did not follow its own policy requiring measurable objectives and timeframes for all identified needs.