Incomplete Care Plan for Medication Refusals
Penalty
Summary
The facility failed to ensure a complete and accurate comprehensive care plan addressing medication refusals for a resident who began refusing multiple prescribed medications, including those for hyperlipidemia, diabetes, depression, gastroesophageal reflux disease, hypertension, and sleeplessness, starting the day after admission. Documentation showed that the resident's medication refusals were frequent, yet the care plan only included a focus statement regarding the resident's resistance to care and medication refusal, without any corresponding goals or interventions. The Director of Nursing acknowledged that the care plan for medication refusals was not completed in a timely manner, and no further information was provided during the complaint investigation.