Failure to Accurately Assess and Document Antipsychotic Medication Use
Penalty
Summary
The facility failed to accurately assess and document the use of antipsychotic medication for one resident. According to the Resident Assessment Instrument (RAI) Manual, facilities are required to record the number of days antipsychotic medications are administered during the 7-day lookback period prior to the Minimum Data Set (MDS) assessment. For the resident in question, medical records showed an active order for Seroquel (Quetiapine Fumarate) 150 mg twice daily, and the Medication Administration Record (MAR) confirmed that the medication was administered at 8:00 AM and 8:00 PM during the relevant period. However, the MDS assessment did not reflect that the resident had received antipsychotic medications during the 7-day lookback period. The resident had multiple diagnoses, including epilepsy, dementia, schizophrenia, anxiety disorder, traumatic brain injury, and other conditions. The care plan indicated ongoing use of antipsychotic medication for psychosis and schizophrenia. Despite this, the MDS assessment failed to accurately code the administration of antipsychotic medication, as confirmed by the Regional Director of Clinical Services during an interview. This discrepancy between the medical record, care plan, and MDS assessment led to the identified deficiency.