Failure to Develop Comprehensive Care Plans for Contractures and Psychotropic Medication Management
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with contractures and those receiving psychotropic medications. For two residents with contractures, one was observed wearing a right arm splint and exhibiting deformity of the right lower extremity, while another had visible contractures of the right arm and hand. Despite documented diagnoses such as hemiparesis, muscle weakness, and spastic hemiplegic cerebral palsy, the care plans for these residents did not address the management of contractures, use of splints, or interventions to prevent further limitations in range of motion. Additionally, five residents with psychiatric diagnoses, including major depressive disorder, schizoaffective disorder, bipolar disorder, and depression, were receiving multiple psychotropic medications. However, their care plans did not include documentation addressing the residents' psychiatric diagnoses or the management and monitoring of their psychotropic medications. The facility's own policies require ongoing evaluation of the effects of psychotropic medications and the inclusion of measurable objectives and time frames in the comprehensive care plan, but these requirements were not met for the affected residents. Interviews with facility staff, including the DON and LPN, confirmed the lack of appropriate care plan interventions for both contracture management and psychotropic medication use. The DON acknowledged the importance of care planning for these areas and confirmed the deficiencies after reviewing the residents' medical records. The absence of these care plan elements was also confirmed through observation, record review, and document review.