Failure to Revise Care Plans After Changes in Medication Therapy
Penalty
Summary
The facility failed to ensure that the care plans for two residents were updated and revised to accurately reflect their current care needs. For one resident with a history of Multiple Sclerosis, the care plan indicated ongoing diuretic therapy, but a review of the Medication Administration Record (MAR) showed that the resident was not receiving any diuretic medication. This discrepancy was confirmed by the LPN Assessment Coordinator, who acknowledged that the care plan should have been revised to reflect the discontinuation of the diuretic therapy, but it was not. For another resident with a diagnosis of necrotizing fasciitis, the care plan documented that the resident was receiving anticoagulant therapy. However, the MAR revealed that the resident had not received any anticoagulant medications since a specific date. The Nursing Home Administration confirmed that the resident was no longer on anticoagulant therapy and that the care plan should have been updated accordingly, but this revision did not occur. These findings were based on clinical record reviews and staff interviews, and they demonstrate a failure to revise care plans following changes in residents' medication regimens.
Plan Of Correction
Care plan for R4 and R9 was discontinued immediately and a modified care plan was shown to the surveyor. The Nursing Home Administrator educated the MDS Coordinator, Director of Nursing, and other members of the interdisciplinary team on the need to ensure care plans are being discontinued when medication orders are discontinued. A whole house medication audit for the last 30 days will be completed, and any modifications needed to care plans will be completed as appropriate. Members of the interdisciplinary team will audit discontinued orders daily (Monday through Friday) for three weeks to ensure all appropriate care plans have been discontinued. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.