Failure to Review and Revise Care Plans for Anticoagulant Use and Pressure Ulcers
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for two residents as required. For one resident with diagnoses including atrial fibrillation and cardiomyopathy, the clinical record showed a physician's order for Xarelto, an anticoagulant, but the care plan did not include a focus area related to anticoagulant medication. The Director of Nursing stated that they believed an adequate care plan had been enacted, but review of the documentation did not support this. For another resident with stage 3 pressure ulcers on the sacrum and back, wound evaluations documented the ongoing presence of these wounds over several weeks. Despite this, the resident's care plan did not include a focus area related to pressure wounds or skin care. The Director of Nursing indicated that the care plan for ongoing skin care had been inadvertently removed. These findings were based on clinical record reviews, wound evaluations, observations, and staff interviews.