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F0657
D

Failure to Timely Develop Comprehensive Care Plans for Psychotropic Medication Use

New Bern, North Carolina Survey Completed on 09-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive care plan within 7 days of completing the comprehensive assessment for two residents who were prescribed psychotropic medications. For one resident with non-Alzheimer's dementia, anxiety, and major depressive disorder, the admission MDS assessment indicated the use of antianxiety and antidepressant medications, and the Care Area Assessment (CAA) was triggered for psychotropic medication use. However, the comprehensive care plan created did not address psychotropic medication use. Staff interviews revealed that the care plan was not created due to human error, and there was confusion among staff regarding responsibility for care plan updates. Similarly, another resident with anxiety, depression, and Alzheimer's dementia was prescribed antianxiety medication, and the CAA was triggered for psychotropic medication use. The care plan for this resident also failed to address psychotropic medication use. Staff interviews indicated that the lack of a clearly identified person responsible for updating care plans after new medication orders contributed to the deficiency. Both the DON and Administrator acknowledged that psychotropic medication use should have been included in the care plans for these residents.

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