Failure to Individualize Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with generalized anxiety disorder who was prescribed Buspirone, Trazodone, and Sertraline for anxiety. The care plan did not identify resident-specific targeted behaviors, non-pharmacological interventions, or measurable goals of treatment, as required by the facility's own policy. Instead, the care plan included generic interventions and listed behaviors that were not observed in the resident, such as disrobing, inappropriate responses to verbal communication, and aggression toward staff or others. Record reviews showed that the resident had moderate cognitive impairment, required assistance with activities of daily living, and received daily antianxiety and antidepressant medications. The social service and nursing assessments described the resident as pleasant, social, and occasionally perseverative, with no history of the specific behaviors listed in the care plan. The care plan interventions were pre-populated and not tailored to the resident's actual symptoms or needs. Interviews with nursing staff and the DON confirmed that the behaviors listed in the care plan were not exhibited by the resident and that the care plan should have included only resident-specific signs, symptoms, and behaviors. The DON acknowledged that the care plan was missing non-pharmacological interventions and measurable goals of treatment, and that the use of batch orders in the electronic medical record may have contributed to the lack of individualization.