Failure to Incorporate Trauma History and Psychiatric Diagnoses Into Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that incorporated a resident’s known psychiatric diagnoses and trauma history. Record review showed that the resident, an adult female with intact cognition (BIMS score of 15), had documented diagnoses including cognitive communication deficit, restlessness and agitation, unspecified dementia, bipolar disorder, and schizoaffective disorder. A psychologist’s clinical treatment plan documented that she had experienced rape and head injuries while living with others and on the street. Progress notes reflected increased manic behavior and a claim of an alleged rape occurrence. Despite this, review of the resident’s care plan on consecutive days showed that it initially contained no mention of her history of sexual trauma, delusional behavior, or diagnoses of schizophrenia and bipolar disorder. When the care plan was revised, it was updated only to reflect that the resident was a victim of physical abuse, with interventions focused on providing a safe environment, establishing safety and trust, discussing safe and healthy relationship skills, and providing referrals and resources. There continued to be no care plan interventions addressing her delusional behavior or her schizophrenia and bipolar disorder. Interviews with the DON, Administrator, and SW revealed that the DON and nursing staff were responsible for revising care plans, that the DON did not conduct a clinical background check when updating care plans, and that the SW had long been aware of the resident’s sexual assault history and persistent schizophrenia and delusions but did not revise care plans. The facility’s own care planning policy required development of a comprehensive, person-centered care plan based on individual assessed needs, including social services, yet the resident’s documented trauma history and psychiatric conditions were not fully incorporated into her comprehensive care plan. The Administrator acknowledged that nursing should know about the resident’s history and that not having an updated care plan created potential for a negative outcome if important information was missed.
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