Failure to Include Anti-Anxiety Medication Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed an anti-anxiety medication. The resident, who had intact cognition and multiple medical diagnoses including debility, cardiorespiratory conditions, heart failure, asthma, and respiratory failure, was receiving Lorazepam as needed for anxiety. Despite the ongoing administration of this medication daily since March, the resident's care plan did not include a focus area, goal, or interventions related to the use of anti-anxiety medication, behavior monitoring, or monitoring for possible side effects. This deficiency was identified through clinical record review, staff interviews, and policy review. Both the ADON and the Administrator acknowledged that the care plan was missing required elements related to the resident's anti-anxiety medication. The facility's Clinical Care Management policy requires routine assessment, evaluation, and updating of care plans in response to changes in clinical condition, which was not followed in this case.