Failure to Update Person-Centered Care Plan for Psychotropic Use, Wander Guard, and Secured Unit Placement
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple medical and psychiatric diagnoses, including liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension. The resident’s quarterly MDS showed severely impaired cognition (BIMS score of 4), an active diagnosis of anxiety disorder, use of an antianxiety medication, and the presence of a wander/elopement alarm. Record review showed an active order for Lorazepam 0.5 mg twice daily for anxiety and confirmed that the resident wore a Wander Guard device. However, the resident’s care plan, initiated months earlier, contained no focus, goals, or interventions related to Lorazepam use, the Wander Guard, or the resident’s placement in a secured unit. Interviews with staff confirmed awareness of these treatments and safety measures but also confirmed that they were not incorporated into the care plan. The MDS nurse acknowledged knowing the resident was taking Lorazepam and wearing a Wander Guard, had documented the Wander Guard on the MDS, and stated that both the medication and device should have been added to the care plan but were not. The LVN assigned to the secured unit reported that the resident had been placed in the secured unit the prior week for closer monitoring after an episode of shortness of breath requiring oxygen and stated that care plan updates were the responsibility of the MDS nurse or DON. The DON confirmed shared responsibility with the MDS nurse for implementing and revising care plans, acknowledged awareness of the resident’s Lorazepam use, Wander Guard, and recent placement in the secured unit for closer monitoring, and stated that these changes should have been added to the care plan but were not, despite a facility policy requiring ongoing assessment and revision of care plans as resident conditions change.
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