Failure to Develop Comprehensive Care Plan for Mental Health Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's schizoaffective disorder, despite the resident having an active diagnosis and being prescribed Zyprexa for behavioral symptoms such as outbursts of anger. Review of the resident's admission record showed diagnoses including schizoaffective disorder, epilepsy, and hypertension, with the Minimum Data Set indicating intact cognition and a need for moderate assistance with activities of daily living. The resident's order summary confirmed the ongoing use of Zyprexa for schizoaffective disorder, yet no care plan interventions or goals were documented to address the mental health condition, associated behaviors, or the use of psychotropic medication. During an interview and record review, the DON acknowledged the absence of care plan interventions related to the resident's diagnosis, behavioral symptoms, and medication regimen. The facility's policies required comprehensive, person-centered care plans with measurable objectives and timetables to address each resident's medical, nursing, mental, and psychosocial needs. The lack of a care plan meant that staff did not have documented guidance to provide individualized care for the resident's schizoaffective disorder and related needs.