Failure to Develop and Implement Comprehensive Care Plan for Depression
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered comprehensive care plan for a resident diagnosed with major depressive disorder. The care plan did not specify which behaviors staff should monitor related to the resident's depression diagnosis or antidepressant medication, despite a black box warning requiring close monitoring for clinical worsening and emergence of suicidal thoughts and behaviors. Additionally, the care plan lacked documentation of non-pharmacological interventions for depression, did not detail the compulsive or sexually inappropriate behaviors the resident exhibited, and omitted interventions for these behaviors. Multiple progress notes documented ongoing sexually inappropriate and agitated behaviors, but these were not reflected in the care plan. Interviews with staff confirmed that the resident was not being monitored for symptoms of depression or suicidal ideation, and that no non-pharmacological interventions were in place for depression. The care plan also failed to include specific behaviors to monitor or interventions to address the resident's compulsive and sexually inappropriate behaviors. The Director of Nursing acknowledged these omissions, confirming that the care plan did not include necessary monitoring or interventions for the resident's depression or related behaviors.