F0605

D

Lack of Diagnosis, Behavior Monitoring, and Care Plan for Antipsychotic Use

Kewanee, Illinois Survey Completed on 01-06-2026

Penalty

18 days payment denial

Summary

The deficiency involves the facility’s failure to follow its Behavioral Health Services Program policy for the use of psychotropic medications, specifically antipsychotics, for a resident receiving risperidone. The policy dated 1/2023 requires that psychotropic medication care plans include the indication or rationale for use, specific target behaviors, and monitoring for efficacy and adverse consequences. For this resident, the care plan dated 1/6/2026 did not document a psychosis medical diagnosis, did not identify specific target behaviors, and did not include any care plan interventions related to antipsychotic use. The physician’s order sheet listed risperidone 1 mg as related to vascular dementia, mild, with other behavioral disturbance, but there was no corresponding behavioral documentation or behavior tracking in the record to support the need for an antipsychotic.

Surveyor observations and staff interviews further showed an absence of behaviors that would typically warrant antipsychotic use. The resident was observed resting in bed watching a cell phone and later eating lunch peacefully in the dining room, and reported no concerns with the facility. Multiple CNAs and an LPN consistently described the resident as not violent or aggressive toward others, characterizing him instead as impatient, frequently using the call light, and sometimes yelling for help if not assisted quickly. The interim DON confirmed that if there was no psychosis diagnosis, no targeted behaviors, and no care plan addressing antipsychotic use in the record, then the facility did not have the required documentation, and was unable to provide evidence of a mental diagnosis or behavior monitoring to warrant the use of risperidone.