Failure to Develop Care Plan for Insomnia
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency was identified when a resident admitted with a diagnosis of insomnia did not have a comprehensive care plan developed to address this condition. The clinical record showed that the resident was prescribed melatonin as needed for insomnia and received several doses, as documented in the Medication Administration Record. During an interview, a registered nurse confirmed that she would attempt non-pharmacological interventions according to the care plan, but acknowledged that no care plan addressing insomnia was in place for the resident during the relevant timeframe. There was no evidence that the facility developed a care plan with measurable goals and interventions for the resident's insomnia.