Failure to Revise Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that care plans were revised as required for two residents who were receiving psychotropic medications. For one resident with moderate dementia, depression, and anxiety, the care plan did not include the symptoms the resident was experiencing, resident goals, or non-pharmacological interventions, despite the use of anti-anxiety and antidepressant medications. The care plan only listed administering medication as ordered and monitoring for adverse effects. Similarly, another resident with major depressive disorder, who was experiencing hallucinations and delusions and was being treated with multiple antidepressants and an antipsychotic, had care plans that also lacked documentation of symptoms, resident goals, and non-pharmacological interventions. The deficiency was identified through interviews and record reviews, which showed that the care plans for both residents were not updated to reflect their current symptoms or needs, as required by the Resident Assessment Instrument (RAI) manual. The administrator acknowledged awareness of care planning issues and stated that work had begun to address them. The lack of comprehensive and updated care plans was found to have the potential to impact staff knowledge of resident needs.