Failure to Develop Comprehensive Care Plans for Residents on High-Risk Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all the needs of two residents who were prescribed high-risk medications. For one resident with a history of heart failure, hypertension, deep vein thrombosis, and respiratory failure, the care plan did not include goals or interventions related to the use of anticoagulants (apixaban) and diuretics (torsemide and spironolactone), despite these medications being ordered and administered for her conditions. This omission was identified through a review of the resident's Minimum Data Set (MDS), order summary, and current care plan. Additionally, another resident with a diagnosis of diabetes and documented use of insulin was found to have no care plan documentation addressing diabetes management, insulin therapy, or related interventions. The MDS coordinator acknowledged during an interview that the resident's diabetes and insulin use were missed on the care plan. These findings were based on record reviews and staff interviews, and the facility census at the time was 52 residents.