Failure to Implement and Document Care Plan Interventions for Fluid Monitoring and Anticoagulant Complications
Penalty
Summary
The facility failed to implement and document required interventions in the comprehensive care plans for two residents. For one resident with a gastrostomy tube, physician orders required intake and output monitoring every shift and a 24-hour tally each evening. Record reviews revealed missing documentation of intake and output on several shifts and days, and the Director of Nursing confirmed that these interventions were not completed as ordered. Facility policy required that medication and treatment records reflect administration as prescribed by the physician, which was not followed in this case. For another resident taking the anticoagulant Apixaban for NSTEMI prophylaxis, the care plan included an intervention to monitor and document for signs and symptoms of bleeding complications. However, there was no documentation of such monitoring in the clinical record. The MDS Coordinator acknowledged that staff should have entered the monitoring intervention in the resident's order summary for sign-off, and the Administrator confirmed the lack of implementation. Facility policy required monitoring for possible side effects of anticoagulant therapy, including bleeding, which was not documented for this resident.