Failure to Address Depression Diagnosis in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the depression diagnosis for one resident. Review of the resident's face sheet and Minimum Data Set (MDS) confirmed an active diagnosis of depression, along with dementia and diabetes mellitus. The MDS also indicated impaired cognition and total dependence on staff for activities of daily living. Despite these findings, the care plans reviewed from March through August did not address the resident's depression diagnosis, and there were no documented goals or interventions specific to depression. Interviews with the MDS nurse and the Director of Nursing confirmed that the omission of a care plan for depression was contrary to facility policy, which requires all active diagnoses to be addressed with individualized goals and interventions. Both staff members acknowledged that the lack of a care plan for depression meant the resident was not properly monitored or provided with necessary services related to their mental health needs. Review of the facility's policy further supported the requirement for comprehensive care plans to address each resident's medical, nursing, mental, and psychological needs.