Failure to Revise Care Plan for Self-Administration of Medication
Penalty
Summary
The facility failed to revise the care plan for a resident to include staff direction regarding self-administration of a physician-ordered medication, Voltaren gel. The resident had multiple diagnoses, including embolism of the deep veins, malignant neoplasm of the breast, diabetes mellitus, and diabetic neuropathy, and required supervision to partial/moderate assistance for activities of daily living. The resident's care plan, last revised on 04/04/25, directed staff to administer medication as ordered for neuropathy but did not address the resident's ability to self-administer Voltaren gel, despite a physician's order allowing unsupervised self-administration and storage of the medication at the bedside. The electronic medical record lacked an assessment for self-administration of medications, and interviews with the resident and staff confirmed that no such assessment had been completed. The resident reported independently applying the Voltaren gel as needed since it was ordered, without recall of any assessment for self-administration. Both a licensed nurse and an administrative nurse stated that an assessment and care plan revision should have been completed to reflect the resident's ability to self-administer the medication. The facility also lacked a policy for care plan revision.