Failure to Develop and Implement Comprehensive Care Plans for Medication Management
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to medication management and monitoring. For two residents with orders for antibiotics—one for Bactrim for infection prophylaxis and another for amoxicillin following a tooth extraction—there were no care plans created to address the use of these medications. The Infection Preventionist Nurse confirmed that care plans should be developed for each antibiotic order to identify treatment goals and interventions to monitor for potential side effects or adverse effects, but this was not done for either resident. Additionally, a third resident with diabetes mellitus had a care plan in place to manage blood glucose levels, including specific interventions such as administering insulin per sliding scale, monitoring blood sugar, and notifying the physician if levels were outside set parameters. However, the care plan was not consistently implemented or followed, as evidenced by multiple instances of blood sugar readings above 300 mg/dL documented in the Medication Administration Record over two months. The Director of Nursing acknowledged that the care plan should have been followed to address the resident's elevated blood sugars. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables for each resident, to be developed and revised as resident conditions change. Despite this, the facility did not ensure that care plans were developed for antibiotic use or that the diabetes care plan was properly implemented and followed, as confirmed by record reviews and staff interviews.