Failure to Develop and Implement Comprehensive Care Plan for Medication Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to meet the medical and nursing needs of a resident with chronic kidney disease, stroke, and dementia. The resident, who was moderately cognitively impaired, had a care plan that included a general intervention for medications to be crushed when appropriate. However, the care plan did not specify which medications should or should not be crushed, nor did it include special instructions for medication administration, despite facility policy requiring such instructions for residents needing medications crushed. During medication administration, staff routinely crushed all of the resident's medications except for an esomeprazole capsule, including a potassium chloride extended-release (ER) tablet, which was specifically listed by the facility as a medication not to be crushed due to its time-release formulation. Both medication aides interviewed confirmed they crushed the resident's medications except for the capsule. The facility's pharmacist verified that the potassium chloride ER tablet provided to the resident could not be crushed or dissolved and should be administered whole. The Director of Nursing and Administrator both acknowledged that special instructions, such as the need for crushed medications, should be included in the care plan and followed by staff.