Failure to Update Care Plan Following Discontinuation of Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly reviews, to accurately reflect the resident's current condition. Specifically, the care plan continued to include interventions related to blood pressure medication use, despite the resident no longer having an active order for such medication. The resident, an elderly female with diagnoses of unspecified dementia and hypertensive chronic kidney disease, had her blood pressure medication discontinued several months prior, but this change was not reflected in her care plan. Interviews with facility staff, including the ADON, MDS nurse, and DON, revealed that while the interdisciplinary team was responsible for reviewing and updating care plans, the process failed in this instance. The staff acknowledged that the care plan should have been updated to remove references to blood pressure medication, but it was overlooked. The facility's own policy required care plans to be reviewed and revised after each assessment, but this was not followed, resulting in the care plan containing outdated and inaccurate information regarding the resident's medication status.