Failure to Implement Recommended Psychiatric Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident, identified as R97, who displayed mental disorder or psychosocial adjustment difficulty. The resident, admitted on January 31, 2025, had moderate cognitive impairment and was diagnosed with non-Alzheimer's dementia and depression. The comprehensive Minimum Data Set (MDS) assessment dated February 6, 2025, indicated the resident had moderately severe depression. A psychiatry assessment conducted on March 10, 2025, by a Psychiatric Mental Health Nurse Practitioner (PMHNP) revealed that the resident expressed feelings of anxiety and depression, with staff reporting intermittent behavioral disturbances such as agitation and restlessness. The PMHNP recommended starting the resident on Buspar, an anti-anxiety medication, to support anxiety. However, a follow-up psychiatry assessment on March 17, 2025, indicated that the resident reported feeling sad about the state of the world and experiencing visual hallucinations. It was noted that the staff had not started the resident on Buspar as recommended in the previous assessment. The clinical record showed no documented evidence that the facility implemented the Buspar treatment as advised by the PMHNP. This was confirmed in an interview with a Registered Nurse on March 19, 2025, who acknowledged that the facility did not implement the medication as recommended.
Plan Of Correction
1. Resident R-97 is now receiving Buspar 7.5mg BID as ordered. 2. All residents with Psychotropic medication recommendations will be reviewed to ensure treatment and services are received correctly to attain their highest practicable mental and psychosocial well-being. 3. Nurse Educator/Designee will re-educate the professional nursing staff on the policy, "Medication Orders." 4. The DON/Designee will conduct weekly random audits times 2 months to ensure that residents with recommendations for psychotropic medication changes are followed up timely with the physician. 5. Audit results will be reviewed monthly by QAPI Committee.