Failure to Develop and Implement Comprehensive Care Plans for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who were prescribed antipsychotic medications. For one resident with diagnoses including anxiety disorder, depression, and unspecified mood disorder, there was no care plan specific to the prescribed antipsychotic medication, Aripiprazole. Additionally, required interventions such as a baseline Abnormal Involuntary Movement Scale (AIMS) assessment were not completed, and the care plan did not address the black box warning associated with the medication. The Director of Nursing (DON) confirmed these omissions during record review and interview, and the facility's policy required ongoing evaluation of psychotropic medication effects in accordance with the resident's care plan. For another resident with bipolar disorder and schizophrenia, the facility did not create a care plan specific to the prescribed antipsychotic medication, Perphenazine. Although this resident had care plans for other psychotropic medications, there was no individualized plan addressing Perphenazine, as verified by the DON. The facility's policy stipulated that all psychotropic medications should be included in the comprehensive care plan, with measurable objectives and timeframes to meet the resident's needs. These deficiencies were identified through interviews and medical record reviews, which revealed that the facility's practices did not align with its own policies and procedures regarding the use of psychotropic medications and the development of comprehensive care plans. The lack of specific care plans and failure to implement required monitoring interventions for antipsychotic medications were directly observed and confirmed by facility staff.