Failure to Update Psychiatric Care Plan Interventions
Penalty
Summary
A deficiency was identified when the facility failed to update the interventions on a psychiatric care plan for a resident with a history of mood disorder and major depressive disorder. The resident was observed awake in bed, yelling, screaming, and swearing. The electronic medical record showed the resident was prescribed Remeron for depression, and the most recent MDS assessment indicated moderately impaired cognition with no mood indicators. The psychiatric care plan listed an intervention involving follow-up by a specific psychiatric provider agency, but this agency was no longer involved in the resident's care. During interviews, the social worker confirmed that the care plan interventions had not been updated to reflect the current treatment practices, and the DON agreed that interventions should be updated as needed. A review of the facility's care planning policy did not address the updating of interventions when care planning, contributing to the failure to revise the care plan to match the resident's current psychiatric treatment arrangements.