Failure to Complete Pharmacy-Recommended Lab Work and Lack of Non-Pharmacological Interventions in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a pharmacy-recommended laboratory test for a resident receiving antiretroviral therapy was completed. The resident, who had diagnoses including schizophrenia, paranoia, and HIV, had a physician's order for Dolutegravir lamivudine and required regular lab monitoring as recommended by the pharmacy and agreed upon by the physician. The initial lab work was not drawn because the resident was at an appointment, and there was no evidence that the lab work was rescheduled or completed afterward. The Assistant Director of Nursing confirmed that the responsibility to reschedule the lab work fell to the Registered Nurse Supervisor, but there was no documentation or oversight to ensure this occurred. Additionally, the facility did not have a policy in place for laboratory work. The resident's care plan included the use of an antipsychotic medication but did not identify or document alternative interventions for managing behavioral symptoms aside from medication use. The care plan coordinator acknowledged that the care plan should have included non-pharmacological interventions as alternatives to medication, in accordance with facility policy. The facility's care plan policy required that care plans be modified with new or updated interventions, but this was not reflected in the resident's care plan documentation.