Care Plans Lacked Psychotropic Medication and Discharge Planning
Penalty
Summary
The facility failed to ensure that individualized care plans addressed all of the residents' needs, specifically omitting psychotropic medication management and discharge planning for two residents. For one resident with multiple diagnoses including major depressive disorder, hypertension, diabetes, and acute kidney failure, the care plan did not include the prescribed antidepressant medications, despite physician orders for Celexa and Remeron. The Director of Nursing confirmed that medications were not addressed in the care plan as required. For another resident with diagnoses such as hypertension, low back pain, muscle weakness, and unsteadiness, the care plan did not include the resident's discharge plan, even though there was a physician order for discharge to an assisted living facility. The Social Service Director confirmed that the discharge plan was not documented in the care plan. These omissions were identified through record review and staff interviews, and were not in accordance with the facility's care planning policy.