Failure to Develop Comprehensive Care Plans for Residents with Mental Health Diagnoses and Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with specific mental health diagnoses and medication needs. For one resident with a diagnosis of anxiety and behaviors of inability to relax, the facility did not create a care plan addressing these issues or the use of Ativan, an anti-anxiety medication. There was no documentation or monitoring of the resident's behaviors or potential adverse effects related to Ativan use in the Medication Administration Record (MAR), and no physician orders were in place to monitor for these concerns. The Director of Nursing (DON) confirmed that the lack of a care plan and monitoring prevented the care team from properly evaluating the ongoing need for the medication. Additionally, another resident with a diagnosis of schizophrenia did not have a care plan developed to address this condition, despite facility policy requiring individualized care plans for residents with behavioral and psychoactive medication needs. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for partial assistance with activities of daily living. The DON acknowledged that care plans should be initiated upon admission or change of condition and that the absence of a care plan for schizophrenia could result in improper care.