Failure to Develop Care Plans for Anticoagulant Use and Vision Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. One resident, who was cognitively intact and had a diagnosis of paroxysmal atrial fibrillation, was prescribed Apixaban, an anticoagulant, for peripheral vascular disease. Despite this, the resident's care plan did not address the use of the anticoagulant or include monitoring for potential side effects, as confirmed by both record review and staff interview. Another resident, who was cognitively impaired and diagnosed with Alzheimer's disease, dementia, and failure to thrive, had documented vision issues and a recommendation for cataract surgery with follow-up by an eye provider. However, the care plan did not reflect the resident's vision impairment or the recommended follow-up for the cataract procedure. This omission was verified through record review, family interview, and staff confirmation. The facility's policy requires resident-centered care plans that address all psychosocial, physical, and emotional needs, which was not met in these cases.