Failure to Update Care Plans with Current Resident Information and Medication Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information for two residents. For one resident, documentation showed that the resident expressed a desire to be discharged to an assisted living facility, and this was discussed with the guardian and during a care plan meeting. However, the resident's care plan continued to state that discharge was not expected and did not reflect the updated discharge plan or the resident's expressed wishes. For another resident, physician orders were in place for two psychotropic medications, trazodone and mirtazapine, prescribed for circadian rhythm disorder and depression, respectively. Despite these orders, the resident's care plan did not include any interventions or goals related to the use of these medications. The DON confirmed that the care plan lacked the required information for these medications and acknowledged that interventions and goals should have been included.