Failure to Care Plan Psychiatric Diagnoses and Aggressive Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the psychiatric diagnoses and associated behaviors for a resident diagnosed with paranoid schizophrenia. The resident's admission record and Minimum Data Set (MDS) indicated diagnoses of paranoid schizophrenia, restlessness, agitation, emotional lability, and severe cognitive impairment. Despite these documented conditions and the resident's known behaviors of aggression and striking out at others, there was no care plan in place to address these psychiatric issues or the manifesting behaviors. Interviews with facility staff, including an LVN and the DON, confirmed that care planning for psychiatric diagnoses and related behaviors is required to prevent incidents and protect other residents. A review of the resident's care plans since admission revealed that none addressed the schizophrenia diagnosis or the aggressive behaviors. The facility's own policy and procedure on care planning required a comprehensive care plan for each resident, but this was not followed in this case.