Failure to Address Behavioral Health Needs in Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a documented history of aggression, refusal of care, and use of psychotropic medication for behavioral management. The resident, diagnosed with Alzheimer's disease, intermittent explosive disorder, major depressive disorder, and generalized anxiety disorder, had a comprehensive care plan that did not include goals or interventions addressing her behavioral diagnoses or medication management. Despite documented incidents of aggression and care refusal, these behaviors were not reflected in the care plan, and there was no documentation of behavioral monitoring related to her medication. Record reviews showed that the resident had active orders for Depakote for intermittent explosive disorder and had previously been prescribed Lexapro, which was discontinued. Behavioral monitoring records indicated multiple instances of care refusal and aggression over two months. Interviews with staff, including LVNs, the MDS Coordinator, the DON, and the AD, revealed a lack of awareness and implementation of specific behavioral interventions for the resident. Staff acknowledged that interventions such as redirection and medication management were used but were not documented in the care plan, and there was no consistent communication or morning meetings to relay this information. The facility's policy required staff to recognize behavioral changes, implement relevant care plan interventions, and monitor and report changes in condition. However, the MDS Coordinator admitted to missing updates in the care plan, and the DON was unsure of the care plan's contents regarding behavioral interventions. The absence of documented interventions and goals in the care plan for the resident's behavioral health needs constituted a failure to provide care in accordance with the comprehensive assessment and plan of care.