Failure to Include Dementia Diagnosis and Antipsychotic Use in Baseline Care Plan
Penalty
Summary
The facility failed to include a diagnosis of dementia and the use of the antipsychotic medication quetiapine on the baseline care plan for a resident upon admission. This oversight was identified during a review of the resident's admission records and baseline care plans. The resident was admitted with a diagnosis of dementia and was prescribed quetiapine for adjunct treatment of depression manifested by physical aggression. However, these critical details were not reflected in the baseline care plan, which is intended to provide initial instructions for resident-centered care. During an interview, the Director of Nursing acknowledged the importance of including a dementia diagnosis in the baseline care plan to address specific behaviors and challenges. The omission increased the risk that the resident's needs related to dementia might not be optimally addressed, potentially leading to a decline in their well-being. Additionally, the failure to document the use of quetiapine in the care plan increased the risk of adverse effects from antipsychotic therapy, particularly in residents with dementia.
Plan Of Correction
The comprehensive care plan may be developed instead of the baseline care plan for diagnoses such as dementia and the use of psychotherapeutic medications within 48 hours of the resident's admission. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development provides education regarding the baseline care plan, including pertinent diagnoses which may affect the residents' psycho-social well-being and use of psychotherapeutic medications during new employee orientation, annually, and as indicated when a variance to performance is identified. The MDS Nurse completes verification of the resident's comprehensive plan of care no later than 21 days following admission and evaluates the completion of the baseline care plan to identify any process concerns. The MDS Nurse will report significant trends to the DON for further review, analysis, and correction. The DON/designee will report significant trends identified in the MDSN and IDT audits to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction; or for the purpose of terminating this plan of correction when substantial compliance has been achieved. Allegation of Compliance Date: 3/25/2025. F 655 Not Specified F656 Develop/Implement Comprehensive Care Plan. CFR(s): 483.21(b)(1)(3) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 73 no longer uses Cephalexin, Ciclopirox, and Lotrimin cream. The interdisciplinary team developed and implemented a comprehensive person-centered care plan on 2/26/2025 for: 1. Resident 29's use of continuous positive airway pressure machine. 2. Resident 29's use of Humulin R insulin. 3. Resident 52's use of Insulin NPH. 4. Resident 97's preference for female caregivers. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; Residents who use CPAP machines, Insulin to treat diabetes, and residents with preferences for a specified gender of caregiver are potentially at risk. The MDS nurse/designee ran a report of residents with diabetes; The Director of Medical Records ran a report of residents who use CPAP machines on 3/20/2025.