Failure to Implement Non-Pharmacological Interventions for Depression
Penalty
Summary
A deficiency was identified when a facility failed to ensure that non-pharmacological interventions were implemented for a resident who was receiving psychotropic medication for depression. The facility's policy required that non-pharmacological interventions be attempted unless contraindicated, in order to minimize the need for psychotropic medication, use the lowest possible dose, or discontinue the medication. However, review of the medical record for a resident with a diagnosis of depression and cognitive impairment revealed that, despite ongoing episodes of depression manifested by crying spells, there was no documentation that non-pharmacological interventions were identified or implemented. The resident in question had a history of memory problems and severely impaired cognitive skills for daily decision making. The resident was prescribed mirtazapine, an antidepressant, to be taken at bedtime for depression as manifested by crying. Over a period of time, the resident experienced 56 episodes of depression, specifically crying spells, while on this medication. Despite these ongoing symptoms, the medical record did not show any evidence that alternative, non-drug interventions were considered or used to address the resident's depressive episodes. During interviews, both an LVN and the DON confirmed that the resident was receiving mirtazapine and had multiple episodes of depression, but they were unable to provide documentation of any non-pharmacological interventions being used. The lack of such interventions was contrary to the facility's own policy and federal requirements, resulting in the resident being at risk of receiving unnecessary psychotropic medication.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 89 was identified as affected by this concern. Resident is currently receiving a routine antidepressant medication. It was noted during an interview on 7/22/2025 that LVN 2 was unable to readily identify where non-pharmacological interventions (NPI) were documented in the medical record. On 7/22/2025, the DON educated LVN on how to locate NPIs in the care plan and the importance of documenting NPIs when resident behaviors are observed. Resident 89's plan of care was updated to include NPI for depression and making sure licensed nurse is documenting Resident 89's behavior when it occurs and when NPI was provided. 2. Identify Other Residents Who May Have Been Affected by the Deficient Practice: Residents receiving psychotropic medications may have been impacted by this issue. On 8/4/2025, the DON and Unit Manager audited 10 random residents' medical records receiving psychotropic medication and found no other issues noted. From 8/5/2025-8/8/2025, the Director of Nursing (DON) or designee in-serviced all licensed nurses about residents receiving psychotropic medication, in particular routine psych medications, to include NPIs and recording behavior per facility policy and procedure. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The DON or designee will oversee ongoing education and compliance monitoring. All residents on psychotropic medications will continue to have care plans that include individualized NPIs. From 8/5/2025, licensed staff received continued education on documenting behavioral observations and corresponding NPIs in the medical record. Medical records or designee will review all new psychotropic medication orders daily, including new admissions and re-admissions, and report findings to the DON. New orders will be reviewed in clinical meetings to ensure NPIs are considered and included in the resident's care plan by the interdisciplinary team (IDT), as appropriate. Resident's plan of care will be updated per facility policy and procedure. 4. Facility plans to monitor effectiveness of the corrective actions and sustain compliance: Integrate QA Process: The DON or designee will monitor the effectiveness of the process. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 194 was affected by this deficient practice. Resident 194 was no longer in the facility. On 7/22/2025, the Medical Record Director sent a copy of the resident 194 Notification of discharge to the ombudsman. On 8/5/2025, the Administrator in-serviced Medical Records, Social Services, and the Case Manager on the process of notifying the ombudsman of any resident transfer or discharge per facility protocol. From 8/5/2025-8/8/2025, the DON in-serviced all licensed nurses about the facility policy and process for notifying the ombudsman about resident discharges and transfers. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents discharged were potentially affected by this deficient practice. On 8/5/2025, medical records were audited for transfers and discharges in the last 30 days to ensure notification of the ombudsman was done, and no other issues were noted. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The administrator or designee will oversee the process. Social Services and the Case Manager will notify the ombudsman for any resident discharge to the community, and Medical Records will notify the ombudsman for any resident transferred to an acute setting. Medical records will audit residents' medical records when discharged or transferred to ensure notification of the ombudsman was completed. The administrator or designee will review the notification of ombudsman log monthly for three months to ensure it's completed.