Failure to Individualize Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to properly identify and document non-pharmacological interventions and targeted behaviors in the care plans for three residents who were prescribed high-risk psychotropic medications. For one resident with severe cognitive impairment and diagnoses including anxiety and dementia, the care plan did not include non-pharmacological interventions to be attempted prior to administering opioid or antipsychotic medications, despite the resident receiving these medications multiple times. Staff interviews confirmed that such interventions and targeted behaviors should have been documented in the care plan. Another resident with moderate cognitive impairment and multiple psychiatric diagnoses was prescribed antipsychotic and antidepressant medications. The care plan for this resident did not specify target behaviors related to the use of psychotropic medications or non-pharmacological interventions. Instead, it contained general statements and lacked focus areas with goals and interventions specific to the resident's psychiatric conditions. The facility also failed to individualize the care plan to address the resident's specific needs and behaviors. A third resident with severe cognitive impairment and diagnoses of Alzheimer's, dementia, anxiety, and depression was prescribed several psychotropic medications. The care plan did not identify target behaviors related to the use of these medications or provide person-centered interventions for anxiety and depression. Staff acknowledged that the care plans contained generic statements and did not provide individualized or specific information regarding the use of antipsychotic medications and related behaviors. The facility's policy required care plan goals to be resident-oriented and measurable, but this was not reflected in the care plans reviewed.