Failure to Develop Person-Centered Care Plan for New Prednisone Therapy
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan for a resident’s new prednisone therapy. The resident was originally admitted with multiple diagnoses including muscle weakness, dysphagia, hypertensive heart disease with heart failure, and COPD. An MDS assessment documented moderate cognitive impairment and a need for partial to moderate assistance with toileting, bathing, and applying footwear. The physician issued a telephone order for prednisone 20 mg by mouth once daily for five days for cough, and this order was documented on the resident’s Order Summary Report. Despite the new prednisone order, licensed staff did not create a care plan addressing the resident’s prednisone use. During interview, the ADON stated that the purpose of a care plan is to create goals and address resident needs, and acknowledged that staff did not develop a care plan for this medication. The ADON explained that a care plan should have included goals and interventions such as monitoring vital signs and potential side effects, and directing staff to notify the physician if side effects occurred. Review of the facility’s policy on comprehensive person-centered care plans showed that care plans must include measurable objectives and timetables, be based on data gathering and clinical decision-making, address underlying problems, and be revised as resident conditions change. The absence of a care plan for the resident’s prednisone therapy was inconsistent with this policy.
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