Failure to Revise Care Plan After Initiation of Psychoactive Medication
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following the initiation of Depakote, an antiseizure medication prescribed for mood disorder. The resident, an elderly male with Alzheimer's disease and unspecified dementia, was admitted with significant cognitive and functional impairments, including being always incontinent, requiring maximal assistance with activities of daily living, and having unclear speech. Despite a new order for Depakote being initiated and later discontinued and re-initiated, there was no evidence that the resident's care plan was updated to reflect this change in medication as required by facility policy. Interviews with facility staff confirmed that the standard practice was for the nurse receiving the medication order to update the care plan, and that psychoactive medications should be care planned upon initiation. Documentation showed that while the medication and its purpose were discussed in a care plan meeting with the resident's representative and family, the actual care plan was not revised to address the new intervention. Facility policies required care plan updates upon status changes and initiation of psychoactive medications, but these procedures were not followed in this instance.