Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
A deficiency was identified when the facility failed to develop a person-centered care plan addressing a resident's repeated refusal of prescribed medications. The resident, who was admitted with diagnoses including muscle weakness, bladder cancer, and ocular myasthenia gravis, was prescribed pyridostigmine bromide tablets twice daily. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident refused this medication on twenty-eight occasions out of forty-nine opportunities over a period of several weeks. Review of the clinical records revealed no evidence of a care plan to address these medication refusals. This finding was confirmed through interviews with facility staff, including the DON, and was discussed during the exit conference.