Failure to Develop Care Plan for Antipsychotic Use
Penalty
Summary
The facility failed to develop a care plan with resident-specific goals and interventions for the use of antipsychotic medications for one resident. This resident, identified as R69, was admitted with diagnoses including hallucinations and schizoaffective disorder and had an order for Quetiapine Fumarate, an antipsychotic medication. Despite the presence of a Care Area Assessment trigger for psychotropic medication use, the care plan did not include specific goals or interventions related to the use of these medications. During an interview, the MDS Coordinator acknowledged that the care plan for R69 was not updated with the necessary goals and interventions for psychotropic medications. The facility's policy requires that the use of psychotropic medications be reflected in the resident's care plan with measurable objectives. However, the MDS Coordinator mistakenly believed that a goal related to behaviors was sufficient, as the medication was ordered due to behaviors. This oversight was contrary to the facility's policy, which mandates a comprehensive, person-centered care plan with measurable objectives and timeframes for each resident.
Plan Of Correction
The care plan for resident #69 for [R] use was implemented. Unit managers on each unit reviewed all residents on antipsychotic medication to ensure care plans are in place. Those that did not have were implemented. All residents on antipsychotic medication are potentially affected. Director of Nursing inserviced unit managers on care planning all residents with orders for antipsychotic medication. Unit managers or designee will review new admission charts daily for antipsychotic medication and will review residents with new or changes in antipsychotic orders and will implement the care plan. Director of Nursing or designee will review 5 residents on antipsychotic medication weekly to assure care plan is in place and will report all findings to Administrator on a monthly basis. All findings will be reported quarterly during the QAPI meeting for the next 2 quarters by Director of Nursing or designee to the QAPI committee. Evaluation by the committee to determine continuing frequency of audits.