Failure to Revise Behavioral Care Plan and Provide Ordered Psychiatric Follow-Up
Penalty
Summary
A deficiency occurred when the facility failed to develop and revise a person-centered behavioral care plan, document risk versus benefit assessments for care refusals, conduct a root cause analysis, identify triggers for anxiety and agitation, and provide ordered psychiatric follow-up care for a resident with significant cognitive deficits. The resident had a history of refusing care, including bathing, changing soiled clothing and linens, and allowing housekeeping to clean her room. Despite repeated documentation of her refusals and the associated health hazards, the care plan interventions remained unchanged over multiple assessments, and no new strategies were developed to address her ongoing behavioral health needs. The resident was started on sertraline for irritability and anxiety following a psychiatric appointment, with instructions for staff to monitor her response and schedule a follow-up appointment in one month. However, the follow-up appointment was not scheduled as ordered, and this omission was not documented in the care plan. Staff delayed the appointment, hoping to find alternative placement for the resident, despite continued refusals of care and worsening hygiene. The facility was unable to provide documentation of risk versus benefit assessments related to the resident's refusals, and there was no evidence of a root cause analysis or identification of specific triggers for her behaviors. The resident's condition deteriorated, culminating in the discovery of maggots in her skin folds during wound care after ongoing refusals of hygiene and incontinence care. Interviews with staff and family confirmed that the facility had not implemented new interventions or scheduled the required psychiatric follow-up, and that the family had not requested a delay in psychiatric care. The care planning policy required individualized, person-centered interventions, but these were not developed or revised in response to the resident's persistent behavioral health issues.