Failure to Revise Care Plans for Medication Management and Elopement Interventions
Penalty
Summary
The facility failed to revise and update care plans for two residents in accordance with physician orders and changes in their care needs. For one resident with end stage renal disease, hypertension, and diabetes, the care plan did not include interventions or monitoring for pain management, antihypertensive medication, or anticoagulant therapy, despite physician orders for these medications. The MDS Nurse, responsible for updating care plans, confirmed that these areas were missing and acknowledged that the anticoagulant medication, added after her start date, was not incorporated into the care plan. Both the DON and Administrator confirmed that these omissions should have been addressed, with the DON noting that the anticoagulant should have been added when ordered and the other medications upon readmission. Another resident with Alzheimer's disease and severe cognitive impairment had a care plan that continued to list a wander guard intervention after the device had been discontinued by physician order. The MDS Nurse, who completed the relevant MDS assessment and quarterly care plan review, did not update the care plan to reflect the removal of the wander guard. Observations confirmed the absence of the device, and both the DON and Administrator stated that the care plan should have been revised to accurately reflect the resident's current interventions.