Care Plan Not Updated for Self-Administration of New Medication
Penalty
Summary
The facility failed to revise the care plan for one resident following the initiation of a new medication and a self-administration assessment. Specifically, the resident was prescribed Mounjaro, a subcutaneous injectable medication, and was assessed and approved by the interdisciplinary team to self-administer this medication and store it at the bedside. Despite this, a review of the resident's care plan did not show any updates reflecting the new medication or the resident's self-administration status, as required by facility policy. Observations confirmed that the resident kept the Mounjaro syringes in a locked box at the bedside, and an interview with an LPN verified that the care plan had not been revised to include this information. Facility policies require that care plans be updated after each comprehensive and quarterly assessment, and that self-administration determinations be documented in the care plan. The lack of revision meant that staff may not have been aware of the resident's ability to self-administer the medication, potentially leading to confusion.