Failure to Include Psychotropic and Anticoagulant Medications in Comprehensive Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop accurate, person-centered comprehensive care plans that reflected current physician orders and diagnoses for two residents. For one resident with documented diagnoses of depression, history of venous thrombosis, and embolism, the admission MDS showed the resident was receiving antidepressant and anticoagulant medications, including bupropion, citalopram, and rivaroxaban for depression and DVT prevention. However, the resident’s care plan, revised in late October, did not include the resident’s antidepressant medication orders or the diagnoses of venous thrombosis and embolism, nor the associated anticoagulant orders. During interview, the Regional Clinical Nurse confirmed the presence of these orders and acknowledged that the care plan did not document the antidepressant and anticoagulant medications, despite the expectation that such medications be care planned. For another resident admitted in early November with an order for memantine to treat cognitive decline, the physician orders documented memantine 5 mg twice daily. The resident’s care plan, dated shortly after admission, did not include the psychotropic medication memantine or any interventions related to its use. In interview, the Regional Clinical Nurse confirmed that the care plan lacked documentation of memantine and its interventions and stated that all psychotropic medications and their interventions were expected to be included in residents’ care plans.
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