Failure to Develop Comprehensive Care Plans for Behavioral, PTSD, and Hospice Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for two residents. For one resident admitted with major depression, post-traumatic stress disorder (PTSD), and anxiety, the admission MDS documented these diagnoses and the use of two antidepressants, and a later psychiatric note confirmed major depressive disorder, PTSD, and insomnia with ongoing antidepressant therapy. Nursing progress notes from September 2025 onward documented verbal abuse toward staff and refusals of weights and blood draws. The resident’s comprehensive care plan, initiated in April 2025 and last revised in December 2025, included depression, antidepressant use, and rejection of care, but did not include any focus, goals, or interventions related to the resident’s verbal behaviors or PTSD diagnosis. Staff interviews showed that nurse aides recognized the resident as alert, oriented, and sometimes challenging due to refusals of care, and described strategies such as using two aides and leaving the room to allow the resident to calm down before reattempting care. The MDS nurse reported that the resident was not coded for behaviors on any MDS assessments because the behaviors did not occur daily during the look-back periods and believed the social worker handled mental illness and behavior care plans, while the social worker stated she did not complete any portions of care plans and that nursing staff were responsible. The DON acknowledged awareness of the resident’s behaviors and that the resident should have been care planned for verbal behaviors and PTSD, and also stated there was no single person responsible for creating care plans, with any nurse able to update them. In a second case, another resident was readmitted with hospice services following hospitalization, and hospice services began in November 2025, with a significant change MDS confirming hospice. However, the resident’s care plan, last revised in September 2025, lacked any focus area, goals, or interventions for hospice care. The MDS nurse and DON both indicated that hospice services should have been included in the care plan and described that there was no designated individual responsible for care plans, with any nurse able to update them.
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