Failure to Include Dialysis and Anticoagulant Use in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all of the residents' needs, specifically omitting dialysis services and anticoagulant use for two residents. For one resident with a history of fluid overload, coronary artery disease, and renal insufficiency requiring dialysis, the clinical record and staff interviews confirmed that the resident was receiving dialysis three times a week. However, the care plan did not include any focus areas or interventions related to dialysis services, despite orders and staff acknowledgment of the ongoing treatment. Similarly, another resident with diagnoses including atrial fibrillation, heart failure, and a hip fracture was prescribed an anticoagulant (Rivaroxaban). The care plan for this resident did not address the use of the anticoagulant, even though the medication order was present in the record and staff confirmed that such interventions should be included. The facility's own policy requires that care plans be person-centered and developed after comprehensive assessment, but these requirements were not met for the two residents identified.