Failure to Develop Care Plan for Major Depressive Disorder
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's diagnosis of major depressive disorder (MDD). The resident, who was admitted with MDD and had moderate cognitive impairment, was dependent on staff for all activities of daily living except eating and required substantial to maximal assistance for mobility. Despite the resident's diagnosis and ongoing treatment with antidepressant medication, there was no care plan in place to address her MDD, specifically lacking non-pharmacological interventions such as redirection, engagement in activities, or opportunities to discuss her feelings with staff. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that a care plan for MDD was not developed for the resident. Both staff members acknowledged the importance of having a care plan that included non-pharmacological interventions to address the resident's mental health needs. Review of facility policies indicated that comprehensive, person-centered care plans with measurable objectives were required for each resident, and that non-pharmacological interventions should be used to minimize reliance on psychotropic medications. The absence of such a care plan for the resident with MDD constituted the identified deficiency.