Failure to Implement Care Plan and Monitoring for Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to formulate a care plan for anticoagulant use and did not obtain a physician order for monitoring a resident receiving anticoagulant therapy. The resident, who had diagnoses including dementia, Parkinson's disease, and gait abnormalities, was admitted and prescribed Lovenox for deep vein thrombosis. Although the medication was administered as ordered, there was no documented evidence of a care plan addressing anticoagulant use, nor was there a physician order in place for monitoring the resident for potential bleeding or adverse reactions during the course of therapy. Staff interviews confirmed that routine assessments for signs of bleeding, such as bruising, bleeding gums, hematuria, and black tarry stools, were not conducted or documented prior to or during the administration of Lovenox. The lack of a monitoring order meant that no prompts were generated for staff to implement necessary assessments, and the Medication Administration Record did not reflect any monitoring for bleeding or coagulation issues. The facility's own policy required such monitoring and documentation, but these steps were not followed for this resident.