Failure to Care Plan and Document Therapeutic Hold for Medication Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including schizophrenia, anxiety disorder, and psychosis. The resident was known to reject care daily and had a history of restlessness, agitation, and aggressive behaviors. Despite these identified needs, the care plan did not include specific interventions or measurable objectives related to the use of a therapeutic hold for medication administration, even though this intervention was used multiple times. Interviews with facility leadership, including the DON and ADON, confirmed that the use of physical restraint (therapeutic hold) for medication administration was not included in the resident's care plan, nor was there an assessment documenting the need for such restraint. The staff proceeded with holding the resident for medication administration based on verbal orders from the physician and consent from the resident's representative, but without formal documentation, care planning, or staff training on safe restraint techniques. The facility's own policy required that any use of restraint be prescribed, assessed, and included in the care plan, which was not followed in this case. Additionally, there were lapses in documentation and medication administration records, as well as a lack of completion of required consent forms for antipsychotic medication. Staff interviews revealed that non-pharmacological interventions were attempted, but when unsuccessful, the resident was physically restrained by multiple staff members to administer injections. The absence of a care plan addressing the use of therapeutic holds, lack of staff training, and incomplete documentation placed the resident at risk of not receiving care and services consistent with her identified needs and resident rights.