Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop and implement a person-centered care plan to address a resident's repeated refusal of prescribed antianxiety medication, buspirone. The resident, who was admitted with diagnoses including recurrent enterocolitis due to C. diff, generalized muscle weakness, essential hypertension, and anxiety disorder, had intact cognitive skills and was dependent on staff for certain activities of daily living. Despite the resident's ongoing refusal of buspirone over several days, as documented in the Medication Administration Record, there was no care plan created to address this behavior or to guide staff in managing the refusal. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that a care plan should have been developed to ensure appropriate follow-up, including informing the physician and considering a psychiatry consult. The resident reported refusing the medication because it was not effective and had communicated this to nursing staff, but the medication continued to be offered without adjustment to the care plan. Review of facility policy indicated that care plans should include measurable objectives and describe services not provided due to resident refusal, but this was not done in this case.