Failure to Include High-Risk Medication and Diagnosis in Care Plan
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 an accurate, person-centered comprehensive care plan for one resident with a diagnosis of edema. Record review showed that the resident was admitted with edema and had a physician's order for furosemide, a high-risk diuretic medication, to be administered daily. The resident's Minimum Data Set Assessment also indicated the use of a high-risk diuretic. However, the care plan, as revised, did not document the resident's diagnosis of edema or the order for furosemide. During an interview, the Director of Nursing confirmed that the care plan did not include the resident's use of furosemide, despite facility expectations that high-risk medications be included in care plans.