Failure to Develop and Implement Comprehensive Care Plans for Residents with Hearing Loss and PTSD
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, resulting in deficiencies related to unmet medical and psychosocial needs. For one resident with a history of muscle weakness, type 2 diabetes mellitus, and major depressive disorder, the facility did not develop a care plan addressing the resident's impaired hearing. Despite documentation and staff acknowledgment of the resident's hearing loss, no care plan was initiated to guide staff in providing appropriate care for this condition. Another resident, admitted with diagnoses including post-traumatic stress disorder (PTSD), anxiety, opioid use disorder, and muscle weakness, did not have a care plan that addressed PTSD or the use of psychotropic medications for mood disorders. The resident's care plan lacked goals and interventions specific to PTSD and did not include monitoring or management strategies for prescribed psychotropic medications such as sertraline and alprazolam. Staff interviews confirmed the absence of these care plan components and emphasized the importance of such plans for safe and effective care. Facility policy required that baseline and comprehensive care plans be developed upon admission and updated to address all identified needs, including trauma-informed care and the use of psychotropic medications. However, record reviews and staff interviews revealed that these requirements were not met for the two residents, resulting in a failure to provide person-centered care as outlined in facility procedures.