Failure to Develop Comprehensive Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed a psychotropic medication. The resident was admitted with multiple diagnoses, including anoxic encephalopathy, dementia, hypertension, depression, anxiety, insomnia, and dysphagia. A physician's order was in place for Abilify to address behavioral and psychological symptoms of dementia. However, upon review of the resident's care plan, there was no documented evidence that addressed the resident's dementia or the use of psychotropic medication. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan did not include the resident's dementia diagnosis or the associated psychotropic medication. The facility's policy requires that all medical, nursing, and psychological needs identified in the comprehensive assessment, including the use of psychotropic medications, be addressed in the care plan. Staff acknowledged that the care plan was not developed or updated as required by facility policy.