Failure to Revise Psychoactive Medication Care Plan After Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan to reflect changes in psychoactive medication orders and required monitoring. The resident had diagnoses including non-Alzheimer’s dementia, depression, and bipolar disorder, and a Quarterly MDS documented severe cognitive impairment, use of an antipsychotic with an indication, and no documented gradual dose reduction or physician documentation that a gradual dose reduction was clinically contraindicated. The facility’s policy required ongoing assessment and revision of care plans as residents’ conditions changed, but this was not carried out for this resident’s psychoactive medication management. The resident had a care plan for dementia initiated on 09/19/2025 that identified impaired cognition and included interventions such as engaging the resident in simple, structured activities, maintaining a consistent routine and caregivers, and monitoring, documenting, and reporting changes in cognitive function. However, the monitoring/evaluation section did not contain documented evidence of the effectiveness of these interventions. A separate psychoactive medications care plan dated the same day identified use of psychoactive medications related to depression, with interventions to administer medications as ordered, monitor and document side effects and effectiveness, and monitor and record target behavior symptoms per facility protocol. The monitoring/evaluation notes for this care plan also lacked documented evidence that behavior and psychotropic medication effectiveness were being monitored. Physician and psychiatric consult documentation showed multiple medication management decisions that were not reflected in the care plan. A physician’s order dated 12/23/2025 documented Seroquel 125 mg at bedtime for dementia with behavioral disturbance. Psychiatric consults on 09/26/2025 and 11/07/2025 documented the resident as alert, awake, doing well, calm, and recommended continuation of Seroquel 125 mg at bedtime with non-pharmacological interventions, along with instructions for staff to monitor mood and behavior and document accordingly. A subsequent psychiatric consult on 12/29/2025 documented the resident as not doing well on current medication, irritable with disorganized behaviors, with staff reporting poor sleep; the psychiatrist ordered initiation of Trazodone 25 mg every 12 hours, an increase of Seroquel to 150 mg at bedtime, and continued non-pharmacological interventions, again directing staff to monitor mood and behavior and document accordingly. Despite these changes and instructions, there was no documented evidence that the comprehensive care plans were revised to include monitoring for medication effectiveness or mood and behavior problems after the medication adjustments. Interviews with nursing staff and the DON confirmed that care plans were expected to be updated with such changes, and that this had not occurred for this resident.
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