Care Plan Lacked Monitoring for High-Risk Medication Side Effects
Penalty
Summary
The facility failed to revise and update the care plan for one resident to address high risk medications and their potential side effects. Clinical record review showed that the resident had diagnoses of depression and anxiety disorder, with a BIMS score indicating severe cognitive impairment. The resident was prescribed multiple high-risk medications, including two types of insulin, an antipsychotic, and two diuretics. However, the care plan, last revised in February, did not include specific side effects to monitor for these medications. Review of the facility's care plan policy indicated that each resident should have an individualized, comprehensive plan of care addressing all medical and nursing needs. Despite this, the care plan for the resident lacked documentation of side effects related to diabetic, antipsychotic, and diuretic medications. The DON confirmed in an interview that she expected care plans to include this information, but it was not present in the reviewed care plan.