Lack of Social Services Follow-Up After Psychotropic Medication Initiation
Penalty
Summary
The facility failed to ensure the psychosocial well-being of a resident when there was no documented evidence of Social Services following up after the initiation and dosage increases of three separate psychotropic medications. The resident, who was admitted with diagnoses including hypo-osmolality and hyponatremia but no psychiatric diagnoses, was prescribed brexpiprazole and aripiprazole for psychosis, as well as mirtazapine for depression. Despite these significant medication changes, there was no documentation of Social Services assessments or follow-up in the resident's clinical record. Interviews with the Social Services Director revealed that although she visited residents daily, she did not document these visits. The DON confirmed that Social Services should be informed and conduct assessments when psychotropic medications are initiated, and that documentation is necessary for team discussions and care planning. Facility policy also requires the social worker to obtain a comprehensive history and conduct assessments related to psychotropic use, including family interviews and identification of causal factors for behaviors. The lack of documentation and follow-up by Social Services constituted a failure to provide medically-related social services as required.