Failure to Update Care Plan for Antipsychotic Medication Use
Penalty
Summary
The facility failed to develop or revise a comprehensive care plan for a resident who was prescribed Seroquel, an antipsychotic medication. The resident had multiple diagnoses, including bipolar disorder, major depressive disorder, difficulty walking, and a history of schizophrenia, as well as a diagnosis of dementia that was not reflected in the current admission record. The care plan for the use of Seroquel was not reviewed or updated to reflect the resident's current diagnoses or needs, and there was no documentation of nonpharmacological interventions to address the resident's behavioral and psychological symptoms. Interviews with facility staff and the psychiatrist revealed inconsistencies in the resident's diagnoses, with the psychiatrist unable to confirm schizophrenia and instead noting major depressive disorder and dementia as primary concerns. The facility's policy required individualized, updated care plans with specific interventions and goals for psychotropic medication use, but this was not followed. The lack of an updated care plan and nonpharmacological interventions placed the resident at risk for not receiving care tailored to their current condition and medication regimen.