Failure to Include Target Behaviors and Non-Pharmacologic Interventions in Care Plan
Penalty
Summary
The facility failed to include psychotropic medication target behaviors and non-pharmacologic interventions in the care plan for one resident. Record review showed that the resident had diagnoses of anxiety, depression, and osteoarthritis, and was receiving antianxiety, antidepressant, and antipsychotic medications. The resident's Minimum Data Set (MDS) assessment indicated intact cognition, and the electronic health record (EHR) documented a range of behavioral issues, including physical and verbal aggression, socially inappropriate behaviors, and signs of anxiety and agitation. Progress notes and physician orders referenced the need to monitor the effectiveness of medications but did not specify target behaviors for staff to observe or document. The care plan, initiated upon admission, included the use of psychotropic medications but did not identify the specific target behaviors associated with the resident's conditions or outline non-pharmacological interventions for staff to implement. Staff interviews confirmed that the expectation was for care plans to include these elements. The facility's policy required comprehensive, person-centered care plans with measurable objectives, descriptions of services, and inclusion of recognized standards of practice, but these requirements were not met in this case.