Failure to Develop Comprehensive Care Plans for Depression and Bladder Incontinence
Penalty
Summary
Surveyors identified that the facility failed to develop comprehensive care plans for residents prescribed antidepressant medications and for a resident with bladder incontinence. For two residents admitted on antidepressant medications, the care plans did not address the underlying depression diagnosis, lacked documentation of specific symptoms, and omitted non-pharmacological interventions. The care plans focused only on monitoring medication side effects, without including individualized goals or interventions for depression itself. Interviews with facility staff confirmed that care plans were not comprehensive and that staff did not routinely assess or document symptoms related to depression. Additionally, for one resident with a diagnosis of depression and documented occasional bladder incontinence, the care plan did not include any interventions or goals related to bladder care, despite this being noted in the resident's Minimum Data Set (MDS) assessment. Staff responsible for reviewing and updating care plans were unable to provide explanations for the omissions or recall relevant details about the resident's care needs. The lack of a bladder care plan was confirmed during interviews and review of the resident's records. The survey also found that, for one resident, adverse effects from depression medication were documented on several dates, but there was no evidence that these effects were reported to a physician as required by the care plan. The facility did not provide additional information or documentation to explain why the care plan interventions were not followed or why comprehensive care plans were not developed for the residents in question.