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F0656
E

Failure to Develop and Implement Care Plans for Psychotropic Medications

Long Beach, California Survey Completed on 06-26-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement individualized care plans for two residents who were prescribed psychotropic medications. For one resident with diagnoses including dementia, depression, and anxiety disorder, there was no care plan in place for the use of Divalproex, which was ordered to manage sudden angry outbursts related to dementia with behavioral disturbances. The resident's records indicated moderate cognitive impairment and a need for minimal assistance with activities of daily living. Both the LVN and DON confirmed during interviews and record reviews that a care plan for Divalproex was missing, and acknowledged the importance of such a plan for monitoring parameters, potential side effects, and appropriate interventions. Another resident, admitted with bipolar disorder and exhibiting restlessness and agitation, was prescribed Quetiapine Fumarate (Seroquel) for disorganized thought processes. This resident had severe cognitive impairment and was taking antipsychotic medication, but did not have a care plan addressing the use of Seroquel. The DON confirmed the absence of a care plan for this medication and stated that care plans for antipsychotic medications are necessary to monitor side effects and evaluate the effectiveness of interventions. Facility policy requires comprehensive, individualized care plans for each resident, incorporating all diagnoses and medications, but this was not followed for these two residents.

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