Failure to Update Care Plan for New Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s care plan to address the initiation and subsequent dose increase of an antipsychotic medication. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and an admission MDS showing a BIMS score of 10/15 with some memory deficits and need for assistance with ADLs. On one date, a psychiatric APRN documented concerns about possible undiagnosed bipolar disorder, depression, or significant trauma history and ordered a trial of Abilify 2 mg daily for delusional disorder, which was entered as a physician’s order. A later psychiatric APRN note documented ongoing restlessness and yelling out and directed an increase of Abilify to 5 mg daily for psychosis, which was also entered as a physician’s order. From the time Abilify was first ordered through a later review date, the Resident Care Plan did not include any care plan addressing the use of this antipsychotic medication. The RCP from the initial Abilify order date through the survey review date lacked documentation of a care plan to address the antipsychotic, including monitoring for side effects and continued behaviors. During interviews, the DON and Regional Nurse (RN #7) stated that any resident on antipsychotic medications should have a care plan to guide care, and that both nursing staff and the MDS Coordinator are responsible for initiating such care plans; they were unable to explain why a care plan had not been developed despite the medication having been ordered 15 days earlier and noted the resident was missed in weekly psychotropic risk meetings. The MDS Coordinator confirmed that a care plan should have been developed to target the antipsychotic use. The facility’s Care Planning policy required a comprehensive, individualized care plan developed by the IDT, based on identified needs, and reviewed and updated as necessary to reflect changes in resident status, but this was not done for the addition of Abilify for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.