Failure to Update Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for two residents who were prescribed psychotropic medications. For one resident, the care plan initiated did not document the use of an antidepressant or provide directives for staff regarding monitoring for medication side effects, despite physician orders indicating the resident was started on Lexapro for depression. The MDS coordinator confirmed that the antidepressant was not added back to the care plan after the resident returned from the hospital and the medication was prescribed. For another resident with diagnoses of anxiety disorder and depression, the care plan was missing information about the use of an antianxiety medication, non-pharmacological interventions attempted prior to administration, and monitoring for side effects or symptoms related to the medication. The resident's order summary showed a PRN order for clonazepam for anxiety, but this was not reflected in the care plan. The MDS coordinator acknowledged that the antianxiety medication was not listed in the care plan at the time of review.