Failure to Timely Update and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans in a timely and accurate manner for two residents, as required by policy. For one resident with Generalized Anxiety Disorder and Schizoaffective Disorder, the care plan was not updated to reflect a change in the administration frequency of an anti-anxiety medication, clonazepam, from twice daily to three times daily. Despite the physician's order being revised, the care plan continued to list the outdated dosing schedule. Interviews with the ADON, MDS nurse, and DON confirmed that the care plan should have been updated to reflect the current medication order, and that the MDS nurse was responsible for ensuring the care plan's accuracy. Another resident with diagnoses including heart disease, hypertension, and type two diabetes was not care planned for the use of antihypertensive medication, specifically Lisinopril, which had been ordered for hypertension management. The resident's care plan did not reflect the use of this medication, nor did it include interventions related to antihypertensive therapy, despite the resident's active diagnosis and ongoing treatment. The MDS nurse and RMDS both acknowledged that the care plan should have included this information and could not explain why it was omitted. Facility policy requires that comprehensive, person-centered care plans be developed and implemented for each resident, incorporating measurable objectives, timetables, and reflecting current standards of practice. The policy also states that care plans must be revised as residents' conditions or treatments change. In both cases, the failure to update and implement care plans as required resulted in care plans that did not accurately reflect the residents' current medical needs and treatments.