Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident 29, who has diagnoses including hypertension and anxiety disorder, was prescribed medications such as Buspirone for anxiety, Duloxetine for depression, and Enoxaparin as a blood thinner. However, the current care plan for Resident 29 did not include any strategies or actions related to the management of these medications. The Director of Nursing (DON) acknowledged that a baseline care plan should have been in place for these medications. Similarly, Resident 47, diagnosed with chronic obstructive pulmonary disease and heart failure, was found to self-administer nebulizer medications. Despite a nursing progress note indicating that Resident 47 was capable of self-administering and storing medications at her bedside, her care plan did not reflect this practice. The DON confirmed that a baseline care plan should have been developed to address the self-administration and storage of medications for Resident 47. These omissions were identified during a review of the facility's compliance with care planning regulations.
Plan Of Correction
Resident 29's care plan has been updated to address the use of antianxiety, antidepressant, and anticoagulant medication use. Resident 47 is discharged from the facility. A comprehensive review of current residents who self-administer medications, or who take antianxiety, antidepressant, anticoagulant medications will be completed by the Director of Nursing/Designee to ensure that those items are appropriately care planned. The facility will take further steps to validate the problem does not reoccur by re-educating the Unit Managers/RN Supervisors on Ftag 656, Nursing Policy 309 "Medication Self-Administration" and Policy OPS416 "Person-centered care plan." Compliance will be monitored by the Director of Nursing/Designee using the Care Plan Audit. Four audits will be completed weekly x 2 weeks and monthly x 2, and results will be reported to the QAA Committee who will determine the need for further audits.