Failure to Update Care Plan After Medication Discontinuation
Penalty
Summary
The facility failed to revise and update the care plan for a resident after the discontinuation of Alprazolam, a medication used to treat anxiety disorder. The resident, who had diagnoses including anxiety disorder, mood disorder, and generalized muscle weakness, was admitted and later re-admitted to the facility. The resident's Minimum Data Set assessment indicated moderately impaired cognitive skills and significant dependence on staff for daily activities. A physician's order was given to administer Alprazolam as needed for anxiety, and the care plan was developed to reflect this intervention, including monitoring for side effects and effectiveness. However, when the physician discontinued the Alprazolam order, the care plan was not updated to reflect this change. Both the assistant director of nursing and the acting director of nursing confirmed during interviews that the care plan should have been discontinued when the medication was stopped. The facility's policy required ongoing assessment and revision of care plans as resident conditions changed, but this was not followed, resulting in the care plan inaccurately reflecting the actual care provided to the resident.