Failure to Develop and Implement Comprehensive Psychotropic and Behavior Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple psychiatric and medical diagnoses who was receiving psychotropic medications. Record review showed that the resident, an older male with metabolic encephalopathy, vascular dementia, diabetes, schizophrenia, schizoaffective disorder, and insomnia, had a quarterly MDS indicating severe cognitive impairment, use of high-risk medications (including antipsychotics and antidepressants), and functional limitations requiring assistance with ADLs. Despite these identified needs and conditions, the current care plan initiated in late December did not identify any behaviors, did not address the use of psychotropic medications, and did not include individualized behavior-based interventions. The record further showed that the resident had active orders for multiple psychotropic and related medications, including IM haloperidol as a one-time dose for restlessness and agitation, PRN Xanax for restlessness and agitation, mirtazapine for insomnia, Seroquel for vascular dementia, trazodone for depression, and Depakote for vascular dementia. The MAR documented administration of PRN Xanax and PRN IM Haldol during the review period. However, the resident’s current care plan did not address these medications, their indications, or associated behavioral symptoms, and did not incorporate the acute behavioral incidents that led to the PRN antipsychotic and anxiolytic use. Interview with the MDS nurse revealed that a change of ownership and transition to a new online system resulted in existing care plans not transferring, requiring all residents’ care plans to be rebuilt. The MDS nurse stated she was responsible for care planning residents on psychotropic medications and acknowledged that, during this transition, she had not yet updated this resident’s care plan, even though the resident was on her list. She was uncertain whether other licensed nurses could update care plans for acute or new issues. The facility’s own policy on comprehensive person-centered care plans required measurable objectives, timeframes, and ongoing revision of care plans as residents’ conditions changed, including addressing underlying sources of problem areas, but these requirements were not met for this resident’s behavioral and psychotropic medication needs.
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