Failure to Update Care Plan After Change in Medication Self-Administration Status
Penalty
Summary
The facility failed to revise the care plan for one resident after a change in the resident's medication self-administration status. The resident, who had multiple diagnoses including end stage renal disease, asthma, type 2 diabetes mellitus, and a history of sudden cardiac arrest, was previously permitted to self-administer medications as documented in the care plan. However, after repeated incidents of non-compliance, such as hoarding medications, leaving them at the bedside, and not taking them as scheduled, the DON determined it was no longer safe for the resident to self-administer medications. This decision was supported by a self-administration evaluation indicating the resident was not safe to self-administer medications. Despite this change, the care plan was not updated to reflect the resident's new status. Interviews with the resident, DON, and Administrator confirmed that the care plan continued to state the resident could self-administer medications, and no updated care plan was found. The DON acknowledged responsibility for revising the care plan and admitted the update was missed during the most recent quarterly review.