Failure to Develop Comprehensive Care Plan for Psychiatric Diagnoses
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident that addressed all psychiatric diagnoses and needs. Record review showed that the resident was admitted with multiple psychiatric diagnoses, including bipolar disorder, major depression, insomnia, suicidal ideation, and post-traumatic stress disorder (PTSD). The resident's PASARR Level II evaluation and provider notes further documented these diagnoses and indicated a history of suicidal ideation and the need for specialized services, including counseling. Despite this, the resident's care plan did not address her diagnoses of PTSD, depression, or bipolar disorder. Interviews and policy review confirmed that the resident was receiving medications for depression and anxiety, daily visits from the Social Services Director (SSD), counseling services, and psychiatric follow-up. The SSD acknowledged that the resident's psychiatric diagnoses and PTSD triggers, such as using the telephone, were not included in the care plan. The facility's policy required that the care plan describe all services to attain or maintain the resident's highest practicable well-being, including specialized services recommended by PASARR, but this was not followed for the resident in question.