Failure to Update Care Plan for Behavioral Health Needs
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident to reflect current care needs and services. According to facility policy, care plans must be updated as residents' conditions change and should be reviewed by an interdisciplinary team. However, documentation revealed that a resident with multiple diagnoses, including muscle wasting, depression, diabetic foot ulcer, and Parkinson's disease, exhibited significant behavioral health concerns, such as wrapping a call bell cord around their neck and expressing suicidal ideation. Progress notes indicated the resident was placed on every 15-minute safety checks, and a psychiatric evaluation recommended ongoing behavioral health services. Despite these documented changes and recommendations, there was no evidence that the facility developed or implemented a comprehensive care plan addressing the resident's behavioral health interventions and services. This deficiency was confirmed by both the Regional Clinical Consultant and the Nursing Home Administrator during an interview, who acknowledged the failure to update the care plan in response to the resident's current needs.