Failure to Implement Individualized Behavioral Care Plan Upon Admission
Penalty
Summary
The facility failed to ensure that an individualized care plan addressing behavioral issues was in place for a resident admitted with multiple diagnoses, including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. Upon admission, the resident was known to have inappropriate behaviors and was resistive to care, as documented in the care plan. However, the interventions for these behaviors were not communicated to the Certified Nursing Assistants (CNAs) via the Kardex or CNA report sheets, and there was no documentation of behavioral interventions or management strategies for wandering. Interviews revealed that the Director of Nursing (DON) had concerns about admitting the resident due to behavioral issues noted in hospital records, but no interventions were implemented to address these concerns upon admission. Further interviews indicated that the DON was not present at the time of admission and did not support the decision to admit the resident, citing the facility's lack of a behavior unit and the resident's history of aggressive behavior and need for antipsychotic medication. Despite a referral for psychiatric services being made after admission, there was a lack of immediate action to address the resident's behavioral needs within the first 48 hours. The deficiency was identified during a complaint investigation and affected one resident out of those reviewed for care plans.