Failure to Develop Care Plan for High-Risk Medications
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing the use of high-risk medications for a resident with multiple diagnoses, including hypertension, paroxysmal atrial fibrillation, and nonrheumatic aortic stenosis. The resident was prescribed Eliquis, an anticoagulant, and Hydralazine HCI for hypertension, both of which are considered high-risk medications. Despite ongoing administration of these medications as documented in the medication administration records for several months, there was no care plan in place that included interventions or monitoring specific to these drugs. Record review and staff interviews confirmed that the omission occurred during a transition to a new electronic medical records system, resulting in the failure to create goals and interventions for the resident's use of anticoagulants and antihypertensives. Both the MDS Coordinator and the Director of Nursing acknowledged that the resident's use of these high-risk medications should have been care planned, but this was not completed at the time of the survey.