Failure to Develop Person-Centered Care Plan for Antipsychotic Medication Use
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was prescribed the antipsychotic medication haloperidol. The resident had diagnoses including depression and vascular dementia, with severe cognitive impairment and total dependence on staff for all activities of daily living. The resident was unable to make medical decisions, as documented in the physician's progress note. Despite the initiation of haloperidol for anxiety manifested by agitation, there was no care plan in place addressing the use of this antipsychotic medication. During interviews and record reviews, it was confirmed by both a registered nurse and the Director of Nursing that a care plan specific to the use of haloperidol was not developed for the resident. Facility policy required person-centered, comprehensive, and interdisciplinary care planning, including updates to the care plan with new problems or changes in behavior. The policy also required regular reassessment of psychoactive medication effectiveness. These requirements were not met in this case, as the care plan did not address the antipsychotic medication use.