Failure to Care Plan Repeated Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan addressing a cognitively intact resident’s repeated refusal of prescribed psychotropic medications. The resident had diagnoses including bipolar disorder, restlessness and agitation, and anxiety disorder, and a recent MDS BIMS score of 15 indicating intact cognition. Medication Administration Records for February documented multiple instances of drug refusal for two psychotropic medications, with code "2 - Drug refused" recorded on several dates. Nursing documentation also described the resident cursing at the nurse and refusing morning medications, and a nurse’s note recorded that the resident refused medication despite education, stating, "I don't care to take medication from you or anyone." The resident reported that an LPN continued to offer an antipsychotic medication despite the resident stating she was allergic, and that the LPN said she would document the refusal. Despite these repeated refusals and associated behavioral documentation, the resident’s care plan, as reviewed on March 2, did not include a problem, goal, or interventions related to refusal of medications. The Assistant Social Services Director, who was responsible for completing care plans for behaviors and refusal of medications, confirmed that there was no care plan addressing medication refusal and acknowledged that a resident with three or more refusals should be care planned so interventions could be put in place. She also stated she did not review the MAR but instead relied on the 24-hour report to identify behaviors. Facility policy on comprehensive care plans required that the comprehensive care plan include problems/needs identified in the comprehensive assessment and that care plans be reviewed and updated at least quarterly and more often with changes in condition or newly developed issues. Facility guidelines for resident refusal of treatment/services/medications stated that declined services must be documented in the medical record and included in the resident’s comprehensive care plan, but this was not done for this resident’s repeated medication refusals.
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.