Failure to Care Plan and Monitor High-Risk Medication Side Effects
Penalty
Summary
The facility failed to ensure that the care plans for two residents receiving high-risk medications included monitoring for side effects as required. One resident was prescribed an antipsychotic, antidepressant, diuretic, and opioid pain medication, but their care plan did not specify the side effects to be monitored for any of these drugs. The MDS coordinator confirmed that these omissions were present and stated she was unaware that side effects needed to be included in the care plan. Facility policies directed staff to monitor for side effects of psychotropic medications and to maintain individualized, comprehensive care plans reflecting current care needs. Another resident with diagnoses including heart failure, hypertension, renal insufficiency, diabetes, and dementia was receiving multiple diuretics, including Metolazone and various doses of Torsemide. The care plan for this resident referenced monitoring for loop diuretic use but failed to mention Metolazone and did not list specific interventions to monitor for adverse effects associated with diuretic therapy. The MDS coordinator acknowledged these omissions during an interview.