Failure to Develop Person-Centered Care Plans for Antipsychotic Use and Activities
Penalty
Summary
The deficiency involves the facility’s failure to develop person-centered comprehensive care plans addressing all identified needs for two residents. For one resident with vascular dementia with psychotic disturbance, physician orders dated 07/22/25 showed an ongoing prescription for olanzapine 5 mg every 12 hours for a psychotic disorder, and the December 2025 medication administration record confirmed the medication was being administered as ordered. The resident’s quarterly MDS assessment documented severe cognitive impairment and antipsychotic medication use. However, review of the comprehensive care plan last reviewed on 10/24/25 revealed no care plan focus area related to antipsychotic medication use. In interviews, the MDS Nurse, DON, and Administrator each acknowledged that the MDS Nurse was responsible for developing and reviewing care plans and that an antipsychotic medication care plan with appropriate interventions should have been initiated when the medication was prescribed, but it was missed due to an oversight. The second resident, admitted with vascular dementia and assessed as severely cognitively impaired on the admission MDS, had documented preferences indicating it was very important to listen to music, participate in groups, engage in favorite activities, and attend religious services. A progress note dated 10/26/25 showed the resident was taken from the dementia care unit to the main unit to attend a religious service, and a nurse aide reported the resident frequently attended activities on the dementia care unit. Despite this, the comprehensive care plan last reviewed on 10/28/25 did not contain a focus area related to activities. The Activities Director stated she was responsible for developing activity-related care plan components and that residents should have an activities focus, and the MDS Nurse reported she sometimes assisted with adding such focuses. Both the Activities Director and the Administrator stated that the absence of an activities focus on this resident’s care plan was an oversight.
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