Failure to Include Mental Health Diagnoses in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident, as required by its own policy and federal regulations. The policy states that a comprehensive care plan must be developed within seven days after the completion of the comprehensive MDS assessment, and that all Care Assessment Areas (CAAs) triggered by the MDS should be considered. Record review showed that the resident was admitted with diagnoses including bipolar disorder, PTSD, and hyperlipidemia. The resident's MDS assessment indicated severe cognitive impairment but did not document any behaviors. However, the care plan created for the resident did not include the mental health diagnoses of bipolar disorder or PTSD. Interviews with the DON and the MDS Coordinator confirmed that the care plan was incomplete and should have included the resident's mental health diagnoses. Both staff members acknowledged that it is a collaborative responsibility to ensure all relevant diagnoses are reflected in the care plan. The omission of these diagnoses from the care plan was verified through record review and staff interviews.