Failure to Develop Comprehensive Care Plan for Medication Management
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and time frames to address all of a resident's needs, as required by regulation. Specifically, for one resident with diagnoses including moderate unspecified dementia with agitation, anxiety disorder, and a functional intestinal disorder, the care plan did not address the resident's medical issues related to medication management. The care plan for psychotropic drug use documented the use of Seroquel and included a goal to prevent negative side effects, but did not specify what side effects to monitor for, nor did it include measurable objectives or time frames. Record review showed that the resident had a physician order for Seroquel, with a recent dose reduction, but the care plan was not updated to reflect this change or to list potential side effects. Interviews with nursing staff revealed that care planning was lacking due to time constraints and unclear division of responsibilities among staff. The Director of Nursing confirmed that side effects should have been listed in the care plan, but this was not done. The facility's own policy required that all changes, including medication changes, be promptly addressed in the care plan, but this was not followed in this case.