Care Plans Lacking for Seizure and Opioid Medication Management
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that care plans included problems, goals, and interventions to address specific diagnoses and medication use for two residents. One resident with a diagnosis of epileptic seizures was receiving Lamotrigine and Phenytoin Sodium for seizure management, but their active care plan did not address the seizure disorder or the use of these medications. Another resident was receiving Tramadol, an opioid, but their care plan did not include a problem, goal, or interventions related to opioid use or monitoring for associated risks such as constipation. These omissions were confirmed by the Director of Nursing, who acknowledged that the care plans did not address these issues.