Failure to Develop Comprehensive Care Plan for Resident with Behavioral Needs
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan to address the behavioral needs of a resident with multiple diagnoses, including dementia, depression, anxiety disorder, obsessive-compulsive disorder, and insomnia. The resident was non-weight bearing on the right lower extremity following a toe amputation and required assistance from two staff members for transfers. Despite physician orders and nursing notes indicating the resident's confusion, restlessness, poor safety awareness, and need for close observation, the care plan did not address the resident's behaviors of self-transferring, wandering, or obsessive-compulsive actions. Clinical documentation and staff interviews revealed that the resident frequently got out of bed unassisted, transferred independently despite being non-weight bearing, and entered a roommate's space, sometimes rummaging through belongings or sitting on the roommate's bed. These behaviors were observed by multiple staff members and reported by the roommate, but were not formally addressed in the care plan prior to a significant incident. The Treatment Administration Record also failed to include all relevant behaviors, omitting restless and non-compliant transfer behaviors. Staff, including nurse aides and the nursing supervisor, acknowledged awareness of the resident's behaviors and described redirecting the resident or bringing them to the nurse's station, but did not update the care plan to reflect these interventions. The social worker, responsible for developing non-compliance care plans, confirmed that a care plan addressing these behaviors was not created until after an incident occurred. The Director of Nursing also indicated that a comprehensive care plan should have been developed collaboratively by nursing and social services to address the resident's specific behavioral and safety needs.