Failure to Implement Care Plans for Medication and Activities
Penalty
Summary
The facility failed to implement care plan interventions for two residents, resulting in deficiencies related to medication administration and activity engagement. For one resident with a history of anxiety, bipolar disorder, psychosis, and recent admission from a long-term psychiatric hospital, the care plan required staff to attempt non-pharmacological interventions before administering PRN Ativan. However, on multiple occasions, the medication was given without evidence that these interventions were attempted, as confirmed by both documentation review and the Director of Nursing. Progress notes and the Medication Administration Record did not reflect any non-pharmacological measures being used prior to medication administration on the specified dates. Another resident, who is highly visually impaired and at risk for limited engagement, had a care plan that included specific interventions such as one-to-one visits, reading the daily chronicle, and assistance with adaptive equipment for activities. Review of activity participation records over several months showed that the resident participated in group activities only six times and was not regularly receiving the individualized interventions outlined in the care plan. The Activity Director confirmed that these interventions were not consistently provided and acknowledged missing the decline in the resident's participation. Both cases demonstrate that the facility did not follow the individualized care plans developed to meet the residents' needs. The lack of implementation of non-pharmacological interventions before administering PRN medication and the failure to provide planned activity adaptations and engagement opportunities were confirmed through record reviews and staff interviews. These actions and omissions led directly to the cited deficiencies.