Failure to Individualize Psychotropic Medication Management and Behavior Interventions
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints and were receiving the least restrictive approach for their needs. Specifically, the facility did not provide resident-specific, non-pharmacological care approaches in the behavior care plans for residents who were prescribed psychotropic medications. For example, one resident with diagnoses including bipolar disorder, anxiety, depression, PTSD, and vascular dementia had care plans and physician orders that lacked individualized non-pharmacological interventions and did not include all relevant target behaviors such as physical and verbal aggression or delusions. Additionally, there was no documentation of behavior monitoring for antipsychotic medication use, and medication administration records showed no documentation of behaviors over several months. Another resident with bipolar disorder and dementia was prescribed antipsychotic and mood stabilizer medications, but the care plan did not identify medication-specific target behaviors or person-centered interventions for the mood stabilizer. Physician orders for behavior monitoring failed to include all relevant behaviors such as mania, racing thoughts, and psychosis, despite progress notes indicating the presence of these symptoms. There was also a lack of documentation showing that non-pharmacological interventions were attempted for these behaviors, and staff interviews revealed a lack of awareness and training regarding individualized interventions and behavior documentation. A third resident with schizophrenia and anxiety had care plans and physician orders that listed generic behaviors and interventions, which were not specific to the resident's actual behaviors such as paranoia, removing clothing, and inappropriate use of hand sanitizer. Documentation in the medical record indicated ongoing behavioral issues and medication adjustments, but the care plans and orders did not reflect these changes or provide individualized interventions. Staff interviews further revealed that CNAs and nurses were not familiar with resident-specific behaviors or interventions and relied on generic templates, with limited access to care plans and no formal training on documentation expectations.