Failure to Develop and Implement Behavioral Health Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address the behavioral health needs of a resident with diagnoses including fibromyalgia, morbid obesity, and depression. Although the resident demonstrated intact cognition and did not initially exhibit mood or behavioral symptoms upon admission, subsequent interviews and record reviews revealed multiple incidents of behavioral issues. These included the resident making accusatory statements, threatening staff, requesting not to work with certain CNAs, and engaging in loud, aggressive interactions with staff and family members in the facility lobby. Staff members, including the DON, Unit Manager, and Social Worker, acknowledged awareness of these behaviors but confirmed that no specific behavioral interventions or care plan addressing these issues had been put in place. Despite facility policies requiring the assessment and care planning of behavioral health needs, the care plan for this resident did not reflect her behavioral symptoms or outline measurable interventions. Staff responses to the resident's behaviors were informal and inconsistent, such as having another staff member present during interactions or reassigning CNAs, rather than being part of a documented, individualized care plan. The lack of a formalized care plan addressing the resident's behavioral health needs constituted a deficiency in meeting regulatory requirements for comprehensive, person-centered care planning.