Failure to Care Plan for Medication Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's repeated refusal of medications over an extended period. The resident, a male with a history of traumatic subdural hemorrhage, generalized idiopathic epilepsy, and other significant medical conditions, was admitted with multiple medication orders, including anticonvulsants, antidepressants, supplements, and antihypertensives. Despite frequent and documented refusals of these medications, the care plan did not include measurable objectives, timetables, or interventions specifically addressing the resident's medication refusal behavior. Record reviews showed that the resident consistently refused various prescribed medications, as documented in the electronic Medication Administration Record (eMAR) by multiple medication technicians and nurses. These refusals were noted for critical medications such as seizure medications, blood pressure medications, and supplements, with refusals occurring on numerous dates across several months. Interviews with staff, including medication technicians, nurses, the MDS Coordinator, and administrative personnel, confirmed that the resident's refusals were well known among staff and were communicated during staff meetings and to the medical provider. However, these refusals were not incorporated into the resident's care plan, and there was no evidence of individualized interventions or strategies to address the refusals. Facility policy required that comprehensive, person-centered care plans include measurable objectives and timetables to meet residents' needs, and that care plans be updated as new information became available. Staff interviews revealed an understanding that medication refusals should be care planned, as this would inform all caregivers of the issue and guide appropriate interventions. Despite this, the care plan for the resident did not reflect the ongoing medication refusals, resulting in a lack of documented strategies or goals to address the resident's non-compliance with medication administration.