Failure to Revise Care Plan After Change in Medication Administration Route
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of dysphagia, GERD, and a g-tube, after the physician authorized a change in medication administration from g-tube to oral route. The resident's care plan continued to reference interventions for swallowing food and drinks, such as maintaining an upright position and encouraging small sips or bites, but did not address the new order for oral medication administration. Additionally, the care plan for dysphagia only included speech therapy interventions and did not specify what actions staff should take when administering medications by mouth, despite the resident's ongoing risk for swallowing difficulties. Interviews with the medical doctor and registered nurse confirmed that the care plan was not updated to reflect the change in medication administration, which could lead to confusion among staff. The facility's policy required comprehensive care plans to be developed and revised based on identified problem areas and changes in resident status, but there was no specific policy for revising care plans when triggers or changes occurred. The deficiency was identified through record review and staff interviews, and it was noted that the lack of care plan revision had the potential for repeat occurrences.