Failure to Develop and Implement Care Plan for Anxiety Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident diagnosed with an anxiety disorder. Observation and interview revealed the resident was receiving Alprazolam 0.5 mg orally every 8 hours as needed for anxiety or panic related to their diagnosis. Review of the resident's medical record and care plans showed there was no documentation of a care plan addressing the anxiety disorder or any non-pharmacological interventions to manage anxiety prior to administering medication. When interviewed, the DON stated that care planning was a team responsibility but was unaware that a care plan for the resident's anxiety disorder had not been implemented. No additional explanation or documentation was provided by the facility.