Failure to Update Care Plan for Medication Administration Preferences
Penalty
Summary
The facility failed to revise and update the care plan for a resident with anxiety disorder, borderline personality disorder, and delusional disorder, who exhibited new behaviors when her medications were not administered according to her preferences. The resident, who typically wakes up around 9:00 to 9:30 a.m. but sometimes sleeps later, relies on staff to wake her for morning medications. On the day of the incident, staff attempted to administer her medications but did not wake her, resulting in the medications being marked as not given. When the resident later requested her medications, she became visibly upset, raising her voice, pacing, and repeatedly returning to the medication cart. The situation was only resolved after the clinical registered nurse consultant contacted the on-call physician and obtained an order to administer the medications outside the usual time frame. Review of the resident's care plan revealed it did not address her preferences for wake-up times or being woken for medication administration, despite staff and the resident confirming this was her usual routine. Interviews with staff indicated a lack of awareness and documentation regarding the resident's preferences, and the care plan was not updated to reflect these needs until after the incident occurred. The facility's policy requires a comprehensive, person-centered care plan based on the resident's assessment and preferences, which was not followed in this case.