Failure to Develop Baseline Care Plan for High‑Risk Methadone Therapy
Penalty
Summary
The deficiency involves the facility’s failure to develop a baseline Resident Care Plan (RCP) within 48 hours of admission for a resident receiving a high‑risk controlled substance, Methadone. The resident had diagnoses including long‑term use of opiate analgesic and a wedge compression fracture of the first lumbar vertebra, and the admission evaluation documented that the resident was alert and oriented, required limited assistance with transfers, and was independent with bed mobility. A Methadone chain of custody record showed the resident received Methadone 120 mg per mL over multiple days, and a physician’s order directed Methadone concentrate 120 mg per mL, 120 mg orally once daily for Methadone maintenance therapy. Despite these orders and administration of a high‑risk medication, review of the clinical record did not identify that an RCP had been developed for Methadone use. Interviews with the DON and the MDS Coordinator confirmed that Methadone is considered a high‑risk medication and that a baseline RCP should have been developed by nursing prior to the resident starting Methadone. The DON stated nursing was responsible for initiating the RCP and that the MDS Coordinator was responsible for reviewing RCPs at the 72‑hour care plan meeting and during completion of the admission MDS assessment, but the absence of an RCP for Methadone was not identified at those times. The MDS Coordinator acknowledged that a 72‑hour care plan meeting was held and that she signed the RCP as complete, yet an RCP for Methadone use had not been developed. This failure occurred despite a facility Baseline Care Plan policy directing that a baseline care plan be developed within 48 hours of admission, including initial goals based on admission orders and any health and safety concerns, and that a supervising nurse verify within 48 hours that a baseline care plan has been developed.
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