Failure to Implement and Develop Comprehensive Care Plans for Metabolic and Behavioral Health Needs
Penalty
Summary
The facility failed to implement and document care plan interventions for two residents with specific medical and behavioral health needs. For one resident with a metabolic condition related to hypokalemia, the care plan required quarterly evaluations by a Registered Dietician (RD) to monitor caloric intake and assess nutritional needs. However, there was no documentation that the RD had completed these quarterly evaluations or made nutritional recommendations as indicated. The RD only reviewed residents who triggered for weight loss, and this resident had not triggered for such a review, resulting in the absence of required RD assessments. For another resident with a diagnosis of post-traumatic stress disorder (PTSD), the comprehensive care plan did not include a focus on PTSD or related behavioral health interventions, despite documentation in psychiatric and psychological notes of frequent flashbacks, nightmares, and significant distress. Both the DON and the Minimum Data Set Coordinator confirmed that the care plan lacked a focus on PTSD and acknowledged that it should have been included, as required by the facility's policy for comprehensive, person-centered care plans.