Care Plan Not Updated to Reflect Discontinued Medications
Penalty
Summary
The facility failed to update the care plan for one resident to accurately reflect current care needs. Record review showed that the resident's care plan, last updated on 04/30/2025, listed anticoagulant and antidepressant medications as active, even though the medication administration record indicated that neither medication was in use during the Minimum Data Set (MDS) observation period. The most recent quarterly MDS assessment was completed on 04/23/2025. Facility policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive or quarterly MDS assessment, and as needed. Interviews with the MDS Coordinator RN and LPN confirmed that the care plan should not have included the anticoagulant and antidepressant medications, as the resident was no longer taking them during the relevant period.