Failure to Implement and Monitor Care Plan for Resident Self-Administering Medications
Penalty
Summary
The facility failed to ensure that a comprehensive care plan to monitor newly identified behaviors was followed for a resident with a history of schizophrenia, PTSD, and other mental disorders. The resident, who had moderate cognitive impairment and was under conservatorship, was observed taking a bottle of vitamin D3 from his closet and stated he had been self-administering the medication daily, contrary to the prescribed every-other-day regimen. Staff interviews revealed that the nursing staff were unaware of the presence of this medication in the resident's room, and facility policy did not allow residents to keep medications at bedside or self-administer medications. The resident also disclosed that he had collected other medications in his room since admission and was unsure of their identity or whether he had reported not taking them. Further interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that they were not aware of the resident storing or self-administering medications. The care plan had been updated to address the resident's psychosocial behaviors, such as hiding medications and ordering over-the-counter medications from outside sources, but there was no evidence of behavior monitoring documented in the clinical records or Medication Administration Record (MAR). The facility's policy required comprehensive care plans with measurable objectives and timetables, but this was not implemented for the resident's newly identified behaviors.