Failure to Develop Comprehensive Care Plan for Medication Monitoring
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop a comprehensive care plan for one resident following a comprehensive assessment, specifically omitting a care plan for antibiotic monitoring. The resident in question was admitted with a history of stroke and metabolic encephalopathy and had been on a specific medication since admission. During interviews and record reviews, both the DON and Infection Preventionist acknowledged that the care plan was not specific to the resident's medication and that such a plan should have been in place. The facility's own policy requires comprehensive, person-centered care plans to prevent or reduce decline in residents' functional status, but this was not followed for the resident's antibiotic monitoring.