Failure to Develop and Implement Comprehensive Care Plan for Anxiety Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with generalized anxiety disorder. Despite the resident's documented diagnosis and the prescription of Buspirone (Buspar) for anxiety, there was no care plan addressing either the anxiety diagnosis or the use of the anti-anxiety medication. Record reviews showed that the resident had a history of Parkinsonism, diabetes, cognitive communication deficit, and generalized anxiety disorder, and was assessed as having moderate cognitive impairment. The resident was alert, coherent, and oriented, and expressed difficulty adjusting to the nursing home environment, with observable anxious behaviors and a willingness to participate in therapy. Multiple assessments and progress notes from licensed professionals, including a Licensed Professional Counselor (LPC) and a Psychiatric Mental Health Nurse Practitioner (PMHNP), documented the resident's ongoing anxiety symptoms and the initiation of Buspirone to manage these symptoms. The medication was later discontinued at the request of a family member. Despite these significant changes in the resident's condition and treatment, the care plan was not updated to reflect the anxiety diagnosis or the medication regimen, as confirmed by interviews with facility leadership and staff. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the care plan omission was due to a lack of communication and oversight. The MDS Coordinator was not informed of the new diagnosis or medication, and the nurse who received the order did not complete the required care plan update. Facility policies required that changes in a resident's condition be reported and care plans updated accordingly, but this process was not followed, resulting in the deficiency.