Failure to Complete Comprehensive Depression Assessment and Care Planning for Antidepressant Use
Penalty
Summary
The facility failed to conduct a comprehensive assessment of depression and mood for a resident who was admitted with diagnoses of depression and stroke and prescribed daily Prozac. Upon admission and during a significant change in status, the Minimum Data Set (MDS) assessments did not fully evaluate the resident's depression or mood symptoms, omitting key questions and resulting in incomplete severity scoring. The Care Area Assessments (CAA) for psychotropic drug use documented the use of Prozac but did not include the resident's specific symptoms or any non-pharmacological interventions. Interviews with the MDS Registered Nurse and Social Worker revealed that they only coded the medication and did not assess or document the symptoms or comprehensive needs related to the antidepressant use. Further review of medication records and care conference notes showed that medication reviews lacked documentation of behaviors, their frequency, and non-pharmacological interventions for depression. The care plan did not address or monitor the indications for antidepressant use or interventions, despite the resident declining formal psychological services. A late entry PHQ-9 assessment was submitted, but there was no evidence it contributed to accurate MDS assessments or care planning for the resident's antidepressant therapy.