Failure to Develop Person-Centered Behavior Care Plan for Resident with Paranoia and Delusions
Penalty
Summary
The facility failed to develop a person-centered behavior care plan for a resident with a history of chronic paranoia and delusions. Despite documented evidence in the hospital discharge records and social work notes indicating the resident's diagnoses of schizophrenia, intellectual disability, and post-traumatic stress disorder, as well as specific behavioral concerns such as paranoia around certain staff and delusional beliefs, the care plan did not address these issues. The resident's behaviors included refusing medication from specific staff and expressing fear and distress related to past experiences, which were not reflected in the individualized care plan. Interviews with facility staff, including the Social Worker and Director of Nurses, confirmed that the resident's chronic paranoia and delusions were not included in the care plan, despite facility policy requiring comprehensive assessment and person-centered planning for residents with impaired cognition or mental illness. The omission was identified during a review of the care plan and supporting documentation, which failed to show any interventions or strategies tailored to the resident's behavioral health needs.