Failure to Update and Develop Comprehensive Care Plans for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that comprehensive care plans were properly reviewed, revised, and developed by the interdisciplinary team for two residents. For one resident with diagnoses including anxiety disorder and moderate recurrent depressive disorder, the care plan was not updated to reflect a new diagnosis of depression or the addition of an antidepressant medication. The care plan also lacked interventions to monitor the effectiveness or side effects of the medication, despite documentation in the clinical record and physician orders indicating the presence of depression and the use of antidepressants. The Clinical Support Nurse confirmed that these updates should have been made to the care plan. For another resident with a history of sexual abuse and diagnoses of bipolar II disorder, PTSD, and depression, the care plan did not include PTSD or bipolar disorder, and a trauma-informed care assessment was not completed upon admission. The resident was receiving virtual therapy for PTSD, and there was no physician's order for these psychiatric services in the record. Interviews with facility staff, including the DON and Social Service Director, confirmed that the care plan should have included these diagnoses and that a trauma/PTSD assessment should have been initiated. The facility also lacked a policy specifically addressing comprehensive care plans.