Mental Health Diagnoses Omitted From Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident’s identified needs, specifically omitting mental health diagnoses and related interventions. One resident was admitted with multiple diagnoses including heart disease, bipolar disorder, depression, and anxiety. Review of this resident’s comprehensive care plan showed that the bipolar disorder, depression, and anxiety diagnoses were not documented, and there were no interventions outlining how staff were to address or manage the resident’s mental health needs. In a staff interview, the Resident Service Advocate confirmed that these mental health conditions were not included in the resident’s comprehensive care plan and stated they were excluded in error. This failure placed the resident at risk for her mental health needs to go unmet because her mental health diagnoses were not included in her care plan.
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