Baseline Care Plan Omission for High-Risk Medication
Penalty
Summary
The facility failed to create an accurate baseline care plan for a resident who was admitted with an order for trazodone, an antidepressant medication classified as high-risk. Upon review of the resident's admission record and hospital medication list, it was found that the resident had an order for trazodone to be administered as needed for sleep. The physician's order confirmed the medication and its purpose related to the resident's systolic (congestive) heart failure. However, the baseline care plan developed for the resident did not include the order for trazodone. During an interview, the Director of Nursing confirmed that the resident had an order for this high-risk medication and acknowledged that the baseline care plan should have included all high-risk medications, but it did not in this case.