Failure to Develop and Implement Care Plan for Prescribed Medication
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan for a resident who had been prescribed Pregabalin to treat neuropathic pain. The resident was admitted with multiple diagnoses, including arthritis, muscle weakness, polyneuropathy, and acute pulmonary edema. Documentation showed that the resident had intact cognition and required maximal assistance with activities of daily living. Despite a physician's order for Pregabalin, there was no corresponding care plan outlining the medication's use, monitoring parameters, potential side effects, or necessary interventions. During interviews, both a Licensed Vocational Nurse and the Director of Nursing confirmed that a care plan for Pregabalin was not present in the resident's records. The facility's policy required care plans to be initiated upon admission and revised as needed to ensure proper delivery of care. The absence of a care plan for this medication was acknowledged by staff and was not in accordance with facility policy.