Failure to Develop Comprehensive Care Plan for Sinemet Administration
Penalty
Summary
The facility failed to develop a comprehensive care plan to address medication administration and monitoring for side effects related to Sinemet for a resident who was receiving the medication for Parkinson's disease. The resident, who was cognitively severely impaired and unable to make her own decisions, had a physician's order for Sinemet administered via G-tube, but there was no care plan in place addressing the diagnosis of Parkinson's disease or the use of Sinemet. Additionally, the resident's Minimum Data Set (MDS) did not reflect the diagnosis of Parkinson's disease, and the medication administration records showed periods where Sinemet was both discontinued and restarted without corresponding updates to the care plan or MDS documentation. During interviews and record reviews, it was revealed that staff were unaware of why the Parkinson's diagnosis was not coded in the MDS, and the neurologist's consultation had specifically instructed staff to monitor for adverse reactions to Levodopa, a component of Sinemet. Facility policies required that all services, progress toward care plan goals, and changes in the resident's condition be documented and communicated among the interdisciplinary team, but these requirements were not met in this case. As a result, the resident's medication regimen and potential side effects were not adequately addressed through care planning or interdisciplinary communication.