Failure to Develop Comprehensive Care Plan for Resident with Complex Behavioral Health Needs
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 develop and implement a comprehensive, person-centered care plan for one resident, as required by its own policy. The resident was admitted with multiple diagnoses, including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, a history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder. Review of the resident's medical record and care plan revealed that the care plan did not address suicidal ideations, history of suicidal behavior, PTSD, or substance use/abuse. Facility staff interviews confirmed that these issues were not included in the care plan, despite the expectation that they should have been.