Failure to Develop and Implement Person-Centered Care Plans for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents who were prescribed psychotropic medications. For one resident with diagnoses including generalized anxiety disorder and dementia, there was an active order for olanzapine to manage psychosis and agitation. Despite this, a review of the resident's care plans revealed that no care plan was created to address the use of olanzapine, including interventions to prevent or manage potential adverse effects. The Director of Nursing confirmed that a care plan should have been developed to guide staff in managing the medication's side effects. For another resident admitted with major depressive disorder, hypertension, and atrial fibrillation, there was an order for amphetamine-dextroamphetamine to treat ADHD. The resident was assessed as having the capacity to understand and make decisions and was independent in activities of daily living. However, a review of the care plans showed that no care plan was developed for the use of the ADHD medication. Nursing staff acknowledged that a care plan was required for any medication that could alter a resident's mental state, and the Assistant Director of Nursing confirmed that a care plan should have been written for the psychotropic medication. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables for each resident, including those receiving psychotropic medications. The policies also specified that behavioral interventions and monitoring for effectiveness and adverse consequences should be included. The absence of care plans for these medications meant that staff lacked documented guidance for monitoring and managing the residents' medication regimens as required by facility policy.