Failure to Update Care Plan for Antipsychotic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to revise a comprehensive care plan to address the use of an antipsychotic medication for one resident. The resident was readmitted with diagnoses including dementia with behavioral disturbance, anxiety disorder, anxiety with psychotic features, and recurrent unspecified major depressive disorder. A review of the active comprehensive care plan dated 6/10/25 showed no care plan addressing antipsychotic medication use. Physician orders dated 6/29/25 directed administration of Quetiapine Fumarate 50 mg by mouth in the morning and 100 mg at bedtime for unspecified anxiety disorder and unspecified recurrent major depressive disorder, and the MAR from June through November 2025 confirmed the medication was administered as ordered with observations for side effects and behaviors three times daily. Quarterly MDS assessments documented that the resident was cognitively intact, had verbal behaviors toward others on some days during one look-back period, and was routinely receiving antipsychotic medications. Interviews with facility staff further clarified the circumstances leading to the deficiency. The DON stated she was unaware that the resident’s care plan did not include an antipsychotic medication plan but acknowledged that one should have been in place, and reported that the MDS coordinator or Administrator created and updated care plans. The MDS coordinator reported she was in training and not responsible for creating care plans, stating that the Administrator was responsible for initiating and updating them. The Administrator acknowledged that the resident’s care plan did not include an antipsychotic medication care plan and explained that the previous MDS coordinator had created care plans, and that she had assisted with creating and updating them during the new MDS coordinator’s training. She stated the care plan was missing because the resident had been discharged to the hospital and readmitted without an antipsychotic order, and when behaviors later emerged and the antipsychotic was restarted on 6/29/25, the care plan was not updated to reflect the resumed antipsychotic therapy.
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