Lack of Comprehensive Assessment for Antidepressant Use
Penalty
Summary
A deficiency was identified when a resident admitted with diagnoses of depression and stroke was prescribed an antidepressant medication (Prozac) without a comprehensive assessment for its use. The facility's policy requires documentation of clinical rationale, including assessment of the resident's condition, therapeutic goals, and consideration of non-pharmacological interventions before administering psychotropic medications. However, the resident's medical record, care plans, and medication review forms lacked documentation of specific symptoms of depression, indicators for use, and non-pharmacological interventions. The Care Area Assessments (CAAs) completed by the MDS RN only noted the medication was for depression but did not detail the resident's symptoms or alternative interventions attempted. Interviews with facility staff, including the Unit Manager and Social Worker, confirmed that comprehensive assessments for psychotropic medication use were not completed, and they did not document symptoms or non-pharmacological approaches. Medication reviews and care plans focused on monitoring side effects but did not provide evidence supporting the need for the antidepressant or describe behavioral symptoms and their frequency. Even after the resident declined formal psychological services, there was no plan of care established to monitor or address the indications for antidepressant use.