Failure to Address Medication and Skin Breakdown Risks in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with diagnoses including anxiety, osteoarthritis, asthma, and chronic lung disease, the care plan did not include information about the resident's use of diuretic and antidepressant medications, despite documentation in the Medication Administration Record and the facility's policy requiring care plans to address medications and their potential side effects. This omission left staff without guidance on monitoring for possible medication-related side effects. For another resident with hemiplegia, Parkinson's disease, and muscle wasting, the care plan addressed the risk of impaired skin integrity related to a suprapubic catheter but did not address the risk of skin breakdown on the coccyx. Clinical documentation indicated the presence of an open area on the coccyx, but this was not reflected in the care plan. The Director of Nursing confirmed that care plans should address high-risk medications and all risks for skin impairment.