Failure to Update and Revise Resident Care Plans for Medication Changes
Penalty
Summary
The facility failed to review and revise the care plans for two residents in accordance with their current medication regimens and diagnoses. For one resident with anxiety and dementia, the care plan continued to reference the use of PRN antianxiety medication, despite the medication having been discontinued several months prior. Clinical record review and staff interviews confirmed that there were no current physician orders for antianxiety medications for this resident, yet the care plan was not updated to reflect this change. For another resident with dementia, behavioral disturbances, Alzheimer's disease, and depression, the care plan did not document the use of prescribed antidepressant and antipsychotic medications, even though physician orders and the Minimum Data Set assessment indicated regular use of these medications. Staff interviews confirmed that the care plan should have included these medications, but it was not updated accordingly. These findings demonstrate a failure to ensure that care plans accurately reflected the residents' current treatments and needs.