Failure to Implement Anticoagulant Monitoring Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident receiving anticoagulant therapy. The resident, who had chronic atrial fibrillation and severe cognitive impairment, was prescribed Warfarin and had a care plan in place that required monitoring, documentation, and reporting of adverse reactions such as bruising. Despite this, clinical records and interviews revealed that there was no documentation or reporting of the resident's bruising prior to a specific date, even though the resident was observed with bruises on both arms and reported bruising easily. Nursing staff confirmed that while they usually documented bruising at blood draw sites, there was no current monitoring or documentation for the resident's bruises, and no report was made regarding the bruises on the morning of the observation. The Director of Nursing confirmed that the care plan included monitoring for adverse reactions to anticoagulant therapy, but the weekly nursing summary did not indicate the presence of bruising. The facility's policy required comprehensive, person-centered care plans that reflect recognized standards of practice, but there was no documented evidence that the resident's bruising was monitored or reported as required by the care plan.