Failure to Develop Comprehensive Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing psychotropic medication use for three residents with significant mental health diagnoses. For one resident with major depressive disorder and generalized anxiety disorder, the clinical record showed an active order for olanzapine and documentation in the MDS and Care Area Assessment (CAA) that psychotropic medication use should be care planned. However, the resident's comprehensive care plan did not include any interventions or objectives related to psychotropic medication use. Similarly, another resident with generalized anxiety disorder and depression had ongoing orders for multiple psychotropic medications, with MDS assessments and CAA worksheets indicating the need for care planning in this area. Despite this, the resident's care plan and revision history lacked any documentation of psychotropic medication use. A third resident with Alzheimer's disease and anxiety disorder was also receiving several psychotropic medications, and their assessments triggered the need for care planning, but the comprehensive care plan did not address this. Staff interviews confirmed that it was the facility's expectation to accurately develop care plans, but these were not completed as required.