Failure to Implement and Document Insomnia Care Plan Interventions
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement a comprehensive, person-centered care plan for a resident with insomnia. The resident’s admission record documented multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, major depressive disorder, anxiety disorder, and insomnia. The resident had a physician’s order for Zolpidem Tartrate 5 mg, to be given by mouth as needed for insomnia for 14 days, with instructions that 1 to 2 tablets could be given as needed. The resident’s care plan for insomnia, initiated on 9/12/2023, included specific non-pharmacological interventions such as repositioning/limb elevation, snacks/drinks, redirection/reassurance/emotional support, deep breathing/relaxation exercises, and monitoring and recording the number of hours of sleep, as well as trying measures like avoiding heavy meals, caffeine, and large fluid intake before sleep and offering milk. Review of the resident’s September 2023 nursing progress notes and MAR showed no documentation that the resident’s hours of sleep were monitored or that the listed non-pharmacological interventions were provided. During an interview and concurrent record review, the infection preventionist nurse confirmed that there was no documentation of sleep monitoring or non-pharmacological interventions and acknowledged that the insomnia care plan had not been implemented. In a separate phone interview, the DON stated that if the care plan directed nurses to monitor hours of sleep and provide non-pharmacological interventions, those interventions should have been implemented and documented in the nurse’s notes or MAR. The facility’s policy on comprehensive person-centered care plans, revised March 2022, required development and implementation of care plans with measurable objectives and timetables to meet residents’ needs, underscoring that the required insomnia care plan interventions for this resident were not carried out or documented.
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