Failure to Update Care Plan Following Change in Antidepressant Dosage
Penalty
Summary
The facility failed to conduct a quarterly review and revise the care plan for a resident diagnosed with major depressive disorder (MDD) who was prescribed Remeron. The resident's care plan, last updated to reflect a 15 mg dosage of Remeron, was not revised after the physician changed the order to 7.5 mg. This discrepancy was identified during a review of the resident's records, which showed that the care plan interventions still referenced the outdated 15 mg dosage, despite the medication order having been changed months earlier. The Minimum Data Set Nurse (MDSN) and Director of Nursing (DON) both confirmed that the care plan should have been updated to reflect the new dosage and that the facility's policy requires care plans to be reviewed and revised quarterly or when there is a change in physician orders. The resident, who was admitted with diagnoses including MDD, muscle weakness, and a need for assistance with personal care, continued to be monitored for depressive symptoms. However, the care plan did not accurately reflect the current medication regimen, as it was not updated following the change in Remeron dosage. Both the MDSN and DON acknowledged that this oversight could lead to confusion regarding the correct dosage to be administered, as the care plan was not aligned with the physician's current orders.