Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who consistently refused to take prescribed medications. During observation and interviews, the resident was noted to refuse medications, stating they did not need them, despite having diagnoses including schizoaffective disorder, bipolar disorder, and epilepsy. The resident's medical records indicated severe cognitive impairment and a need for supervision or assistance with activities of daily living. Physician orders documented multiple medications for mental health and seizure management, but there was no care plan addressing the resident's medication refusals. Staff interviews confirmed that the resident routinely refused medications and that facility policy required a care plan to be developed in such cases. The LVN and DON both acknowledged that a care plan should have been created to address the refusals, and the facility's policy specified that care plans must be updated based on assessed needs. Despite these requirements, no care plan was in place to guide staff in managing the resident's medication refusals.