Failure to Develop Comprehensive Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was receiving psychotropic medications. The resident, admitted with diagnoses including epilepsy, anxiety disorder, Parkinson's disease, and adult failure to thrive, was assessed as moderately impaired for daily decision making and was prescribed both antipsychotic and antianxiety medications. Despite these factors, the care plan did not include a measurable or comprehensive approach to the use of psychotropic medications, nor did it identify specific behaviors to be monitored in relation to the administration of antipsychotic drugs. A review of the resident's medical record and care plans confirmed the absence of targeted behaviors or monitoring parameters for the effectiveness of the antipsychotic medications. An interview with a registered nurse further verified that no care plan had been developed for the use of psychotropic medications and that there were no identified behaviors being tracked. Additionally, the facility did not have a policy in place regarding the use of psychotropic medications.
Plan Of Correction
The facility will continue to develop and implement comprehensive care plans. Resident #2 continues to reside in the facility. No negative effects noted. The comprehensive care plan was constructed by the MDS nurse for alteration in mood and behavior on 3/25/2025. Resident #2's current psychoactive care plan was reviewed and modified on 3/25/2025 by the facility MDS nurse. An initial audit of psychoactive care plans was completed by the MDS nurse on 4/15/2025, ensuring facility monitoring of the effectiveness of psychoactive drugs for targeted behaviors identified. Negative findings were corrected by updating care plans. The Interdisciplinary team, responsible for creating and revising a comprehensive care plan, was reeducated by the Regional Clinical Manager on 4/14/2025 to ensure the care plans meet the current needs of the resident. Weekly, for 2 weeks, the DON or designee will conduct a random audit of 5 residents who are taking psychoactive medications, ensuring monitoring for medication effectiveness for targeted behaviors is reflected on the care plan. Negative findings will be corrected immediately by updating the current care plan and reeducating staff. Negative findings will also be reported to the QA committee for review. The Administrator will ensure the completion of the weekly audits. The DON is responsible for ongoing compliance.