Failure to Include Antipsychotic Medication in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included all necessary instructions for effective and person-centered care for a resident. Specifically, the baseline care plan did not address the resident's use of an antipsychotic medication, Olanzapine, which had been ordered and administered for psychosis. The omission was confirmed through record review, which showed that the antipsychotic medication was not included in the baseline care plan until several days after admission, despite being present in the physician's orders and medication administration record from the time of admission. Interviews with the MDS nurse and the DON confirmed that the admitting nurse was responsible for completing the baseline care plan and that the omission of the antipsychotic medication was an oversight. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 2, and diagnoses including dementia and unspecified psychosis. The facility's policy required that baseline care plans be developed within 48 hours of admission and include all physician orders, but this was not followed in this instance.