Failure to Timely Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan in a timely manner for a resident who was prescribed an anti-anxiety medication, Ativan, to be administered prior to dialysis sessions. The resident had multiple diagnoses, including Alzheimer's disease, vascular dementia, chronic kidney disease, and adjustment disorder with anxiety. The order for Ativan was given by the Psychiatric Nurse Practitioner following a request from the Memory Care Director, and the medication was administered regularly as prescribed. However, review of the resident's clinical record and care plans revealed that a care plan addressing the use of Ativan for anxiety was not initiated until over two months after the medication was started. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, confirmed that a care plan should have been created immediately after the Ativan was ordered, but this was not done. The facility's policy on psychotropic management requires that symptoms and therapeutic goals be documented prior to initiating such medications, and that care plans be developed to promote the resident's highest practicable well-being. The lack of a timely care plan for the use of Ativan constituted a failure to meet these requirements.