Failure to Develop Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement a care plan for a resident receiving Seroquel and Duloxetine, which are psychotropic medications. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was admitted to the facility with diagnoses including diabetes mellitus, chronic kidney disease, and bipolar disorder, was assessed to have clear comprehension and the capacity to make decisions. Despite this, there was no care plan in place for the administration of these medications, as confirmed by a registered nurse during a record review. Interviews with the Minimum Data Set Nurse and the Director of Nursing revealed that care plans are essential for providing individualized care and ensuring that residents' needs are met. The facility's policy and procedure documents also indicated that a comprehensive, person-centered care plan should be developed for each resident, including those receiving psychotropic medications. The absence of a care plan for the resident's psychotropic medication use was acknowledged by the staff, highlighting a lapse in the facility's adherence to its own policies and procedures.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Minimum Data Set Nurse (MDSN) Assistant care planned the psychotropic medication, Seroquel and Duloxtine, for Resident 46. The care plan included the use of the psychotropic medication being a risk, the goal that Resident 46 will remain free of psychotropic drug-related complications, and the interventions including, but not limited to, providing a safe and calm environment, monitoring for side effects of the use of psychotropics, and encouraging activities of preference. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/11/25, the Medical Records Director conducted an audit on care plans for psychotropic medications, including, but not limited to, Seroquel and Duloxetine. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/10/25, the Director of Nursing in-serviced Licensed Nurses, including but not limited to Licensed Vocational Nurses, including MDSN Supervisor and Assistant, and Registered Nurses on the facility's policy and procedure titled, "Care Planning," with emphasis on a comprehensive person-centered care plan being developed for each resident based on their individual assessed needs, which includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. On 3/10/25, the Director of Nursing in-serviced Licensed Nurses, including but not limited to Licensed Vocational Nurses, including MDSN Supervisor and Assistant, and Registered Nurses on the facility's policy and procedure titled, "Psychotherapeutic Drug Management," with emphasis on nursing responsibility to implement and update the care plan as indicated. The in-service also included not administering psychotherapeutic medication until an informed consent has been obtained and documented by the Attending Physician/LHP (Licensed Healthcare Professional) from the resident and/or surrogate decision maker. The Medical Records Director will conduct an audit daily for 5 days, weekly for 2 weeks, and monthly thereafter on psychotropic medication being care planned. How the facility plans to monitor its performance to make sure that solutions are maintained: The Social Services Director will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for care planning psychotropic medication use for three months or until compliance is met.