Failure to Update Care Plan for Mental Health Diagnoses
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
The facility failed to revise the care plan for one resident to include documentation and interventions for Post Traumatic Stress Disorder (PTSD) and a history of suicide. Clinical record review showed that the resident had a documented diagnosis of PTSD in psychiatric progress notes and a history of severe depression with a suicide attempt, as noted in physician recommendations. However, the resident's care plan, last revised on 4/2/25, did not reflect these mental health needs. Staff interviews confirmed that the care plan should have included PTSD and the history of suicidal ideations, and that the social services coordinator should have updated the care plan based on physician notes.