Failure to Timely Develop and Implement Depression Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan for a resident who was prescribed mirtazapine for depression. The resident was admitted without a diagnosis of depression, but a physician order for mirtazapine to treat depression was entered on 3/26/25. Despite this, a care plan addressing the resident's depression was not initiated until 13 days after the medication was started. During an interview and record review, the DON confirmed that there was no care plan in place for the resident's depression during this period and acknowledged that one should have been developed to ensure appropriate goals and interventions. Facility policy requires individualized care plans to be created based on resident needs and to be accessible to all caregivers, but this was not followed in this instance.