Failure to Address Anticoagulant Use in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing the use of anticoagulant medication for a resident who was admitted with a left femur fracture, dementia, and was prescribed Enoxaparin Sodium for deep vein thrombosis prophylaxis. Despite the resident's severe cognitive impairment and ongoing administration of the anticoagulant, the care plan dated several weeks after admission did not include any focus area or interventions related to anticoagulant use. Record review confirmed that the resident received the anticoagulant medication nightly over a period of nearly a month, yet this was not reflected in the care plan. Interviews with the MDS Coordinator and the DON confirmed that the care plan should have addressed the use of anticoagulant medication, especially given its high-risk nature and potential side effects. The Administrator also stated an expectation that all care plans should reflect residents' clinical conditions, including anticoagulant use.