Failure to Develop Care Plan for Resident with Visual Hallucinations
Penalty
Summary
Facility staff failed to develop and implement a care plan for a resident experiencing visual hallucinations. The resident, who was admitted with unspecified dementia, a history of falls, and quadriplegia, was observed and reported by both nursing and CNA staff to have ongoing episodes of seeing people outside her window attempting to enter her room. These hallucinations had been occurring for several weeks to months, as confirmed by interviews with staff. Despite this, there was no documentation or care plan addressing the resident's hallucinations in her electronic medical record. Interviews with the facility's administrator and social services director revealed that neither was aware of the resident's hallucinations, and both acknowledged that a care plan should have been developed. Review of the facility's policy indicated that a comprehensive, person-centered care plan should be created for each resident, including measurable objectives and interventions for identified needs. The lack of a care plan for the resident's hallucinations constituted a failure to meet this requirement.