Failure to Update Care Plan After Resident's Psychiatric Re-admissions
Penalty
Summary
The facility failed to ensure that a person-centered, comprehensive care plan was reviewed and updated by the Interdisciplinary Team (IDT) to reflect the behavioral care needs of a resident with multiple diagnoses, including Parkinson's disease, dementia, metabolic encephalopathy, and bipolar disorder. The resident exhibited behavioral symptoms such as racial slurs, derogatory comments, verbal and physical aggression, throwing items, and refusing care. The care plan included various interventions to address these behaviors, such as administering medications, providing care in pairs, and monitoring behavior episodes. Despite multiple re-admissions from psychiatric hospital stays, the clinical record lacked documentation of IDT progress notes after each re-admission to indicate that the care plan had been reviewed and revised with new or modified interventions. Facility policy required the care plan to be reviewed and updated upon a resident's status change, with team discussions documented in the nursing progress notes. However, this process was not followed for the resident in question, as evidenced by the absence of updated care plan documentation after each hospital re-admission.