Care Plan Not Updated After Medication Change
Penalty
Summary
The facility failed to update the care plan for a resident after a change in his medication regimen. The resident, who had diagnoses including Alzheimer's disease, dementia, anxiety, hypertension, and reduced mobility, was hospitalized and upon return, his medications were changed, specifically, he was no longer prescribed an antidepressant. Despite this change, his care plan continued to indicate a need for antidepressant medication and included a goal related to avoiding discomfort or adverse reactions to the antidepressant. The oversight was confirmed during an interview with the Regional Nurse Consultant, who acknowledged that the care plan was not updated to reflect the medication changes following the resident's hospital stay. A review of facility policy indicated that changes to the comprehensive care plan should be made on an ongoing basis for the duration of the resident's stay, but this was not done in this case.