Failure to Revise Care Plan for Antipsychotic Use and New Mental Health Diagnosis
Penalty
Summary
The facility failed to revise the care plan for a resident who was readmitted with diagnoses including stroke and depression, and who subsequently received a new diagnosis of bipolar disorder. A physician ordered Risperdal, an antipsychotic, for the resident, and a psychiatric nurse practitioner documented that a gradual dose reduction (GDR) was clinically contraindicated. However, the resident's annual MDS assessment indicated the use of an antipsychotic without a GDR attempt and lacked documentation from the physician stating that a GDR was clinically contraindicated. Record review revealed that the resident's care plan was not updated to address the new diagnosis of bipolar disorder or the initiation of Risperdal. Interviews with the MDS Nurse and DON confirmed that the care plan should have included both the antipsychotic medication and the associated diagnosis, but these were omitted due to a breakdown in communication and lack of notification to the MDS Nurse about the changes. The administrator also acknowledged that the care plan should have reflected these updates.