Failure to Develop Comprehensive Care Plan for Antianxiety Medication
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan to address all of a resident's identified needs, specifically omitting a care plan for the administration of Clonazepam, an antianxiety medication. The resident in question was an elderly female with diagnoses including anxiety, depression, and dementia, and had a severely impaired cognitive status as indicated by a BIMS score of 03. She required maximum assistance with activities of daily living and was receiving Clonazepam both in the morning and at bedtime for anxiety, as documented in her physician orders. However, a review of her comprehensive care plan did not show any mention of Clonazepam or related interventions. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed a lack of clarity regarding responsibility for updating care plans, particularly for acute changes such as new medication orders. Although staff reported discussing resident changes during daily morning meetings, the care plan for this resident was not updated to reflect the use of Clonazepam. The facility's own policy required care plans to be revised as needed based on changes in resident condition, but this was not followed in this instance.