Failure to Address Black Box Warnings in Care Plan for Resident Receiving Psychotropic Medications
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive care plan addressing Black Box Warnings (BBW) for a resident with significant mental health needs. The resident had a diagnosis of psychotic disorder with delusions and high-risk behaviors, and was assessed as having severe cognitive impairment. Despite receiving antipsychotic and antidepressant medications, including Zyprexa and Sertraline, the care plan did not include staff instructions regarding BBW for these medications. The facility's policy required that medications be addressed in each resident's care plan, but this was not done for this resident. The issue was identified through a review of the resident's electronic medical record, Minimum Data Set (MDS) assessments, and care plan documentation. The resident's Medication Administration Record (MAR) confirmed that the medications were administered as ordered. An administrative nurse confirmed the expectation that all BBW medications should be included in the care plan, but this was not reflected in the resident's documentation.