Failure to Update Comprehensive Care Plan After Psychiatric Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect the resident's current needs and services. Clinical record review showed that the resident, who had diagnoses including schizophrenia, depression, and anxiety, was transferred to a hospital for involuntary psychiatric commitment due to verbal and physical aggression. Upon readmission from a behavioral hospital, documentation from the hospital included specific red flags, warning signs, and internal coping strategies relevant to the resident's mental health status. However, the facility's care plan did not incorporate these updated findings, nor did it reflect the resident's recent psychiatric hospitalization or the escalation of behaviors that led to the hospital stay. The care plan, initially created years prior, was not updated to include the resident's current diagnosis of schizophrenia, recent behavioral episodes, or the interventions and strategies identified by the behavioral hospital. Interventions and goals in the care plan were outdated and did not address the resident's present mental health risks or needs. An interview with the director of nursing confirmed there was no documented evidence that the care plan had been reviewed or revised to reflect the resident's current condition and required interventions.