Failure to Develop Individualized Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan to address the use of psychotropic medications for a resident with severe cognitive impairment and a diagnosis of unspecified dementia. The resident had been receiving Zyprexa for agitation and Mirtazapine for depression since admission. The care plan in place did not identify specific targeted signs, symptoms, or behaviors that warranted the use of these medications. Additionally, the care plan lacked individualized, measurable non-pharmacological interventions and did not include measurable goals of treatment or a target date for achieving those goals. Interviews with nursing staff and the DON confirmed that the care plan did not specify resident-specific symptoms or targeted behaviors related to the use of psychotropic medications. The care plan also did not include non-pharmacological approaches tailored to the resident's needs. Review of the resident's care card and medical record further supported that there were no individualized interventions or documentation of targeted behaviors for the use of these medications.