Failure to Update Care Plan After Resident's Psychosocial Change in Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident following a reported change in condition. The resident, who had a history of major depressive disorder and moderate cognitive impairment, reported being struck by an unknown individual and expressed ongoing fear for his safety. Despite this significant psychosocial change, there was no documentation that the resident's care plan was reviewed or updated to address his new needs. Interviews with facility staff, including an LVN, RN Supervisor, and the Director of Nursing, confirmed that they were made aware of the resident's allegation and recognized it as a change in condition requiring care plan review and revision. However, the care plan was not updated after the incident was reported. Staff acknowledged that this omission could result in the resident's needs not being addressed, including unresolved fear and psychosocial distress. A psychological consultation further documented the resident's feelings of being unsafe and persecuted, yet these concerns were not reflected in the care plan. Review of facility policy indicated that care plans should be reviewed and revised for residents experiencing a status change, but this procedure was not followed in this case.