Antipsychotic Medication Administered Without Active Court-Approved Treatment Plan
Penalty
Summary
The facility failed to ensure that a court-approved treatment plan for the administration of antipsychotic medication was active and current for a resident with a legal guardian. The facility's policy requires that residents with guardians must have a valid court-approved treatment plan in place before antipsychotic medications can be administered. Record review showed that the resident, who had diagnoses including schizophrenia and dementia, was under guardianship and had previously been authorized to receive antipsychotic medication through a court-approved treatment plan. However, this treatment plan had expired, and there was no updated or current plan in the medical record. Despite the expiration of the treatment plan, the resident continued to receive Clozapine as ordered by the physician, as documented in the Medication Administration Records. Interviews with the Administrator confirmed that there was no active or updated court-approved treatment plan available, and the most recent plan had expired. The facility did not have a social worker at the time, and efforts to locate or update the necessary documentation were unsuccessful.