Failure to Initiate Medication-Related Care Plans for Two Residents
Penalty
Summary
The facility failed to initiate care plans based on medication use for two residents during a recertification survey. For one resident, a physician order for busPIRone HCl 5 mg oral tablet to be administered every 8 hours for anxiety was present in the medical record, but no care plan addressing the use of antianxiety medication was initiated. The Director of Nursing (DON) confirmed that the care plan had not been started and acknowledged the oversight after being informed by the surveyor. The resident had a history of frequent admissions and discharges, but this was not documented as a reason for the lack of a care plan. Another resident was receiving Eliquis (Apixaban) 5 mg twice daily for deep vein thrombosis (DVT) as ordered by a physician, but there was no care plan in place to address the anticoagulant therapy. The DON confirmed that a care plan for anticoagulant therapy had not been initiated for this resident and acknowledged the concern when brought to her attention by the surveyor. Both deficiencies were identified through medical record review and staff interviews, indicating a failure to ensure care plans were developed and implemented for residents receiving specific medications.