Inaccurate Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure a complete and accurate care plan regarding the use of psychotropic medications for one resident. Specifically, a resident was prescribed Remeron (Mirtazapine) as an appetite stimulant, but the comprehensive care plan incorrectly documented the medication as being used for depression. The care plan included interventions and monitoring related to antidepressant use for depression, despite the absence of a depression diagnosis in the resident's medical record. A review of the resident's physician orders and nutritional evaluation confirmed that Remeron was initiated to address significant weight loss and support increased appetite. The discrepancy was acknowledged by the Director of Nursing, who confirmed that the care plan did not accurately reflect the resident's current needs and medication purpose. No additional information or corrective actions were provided during the survey process.