Failure to Develop Comprehensive, Individualized Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, as required by their own policies and regulatory standards. For one resident, the care plan addressing mood and behavioral symptoms did not include all interventions listed in the resident's Informed Consent Renewal for psychoactive medications. Specifically, non-pharmacological interventions such as encouraging exercise, empathetic listening, individualization of care choices, positive reinforcement, repositioning, and social service or activity visits were documented in the consent form but were not reflected in the resident's care plan. Interviews with facility staff, including an LVN and the MDS Coordinator, confirmed that these interventions were practiced but not formally included in the care plan documentation. For another resident, the facility did not develop a care plan that addressed the recommendations from a PASARR Level II evaluation. The PASARR Level II evaluation, conducted by a psychologist, outlined several personalized care recommendations, including ongoing psychotropic medication monitoring and education, mental health rehabilitation activities, ADL training, supportive services, psychotherapy or counseling, psychiatry consultation, and neuropsychology consultation. Despite these recommendations and the resident's medical history of anxiety disorder, depressive disorder, and bipolar disorder, the care plan did not reflect these individualized interventions. Facility staff, including the MDS Coordinator, Administrator, and DON, verified during interviews and record reviews that the care plans for both residents were incomplete and did not incorporate all required interventions. These omissions were identified through observation, interviews, medical record reviews, and review of facility policies and procedures.