Failure to Develop Individualized Care Plan for High-Risk Medications
Penalty
Summary
The facility failed to develop a comprehensive, individualized care plan for a resident who was cognitively intact and required extensive assistance with daily care tasks. Despite the resident receiving multiple high-risk medications, including an anticoagulant (Apixaban), an antiplatelet (Aspirin), and a diuretic (Lasix), there was no documented evidence that a care plan was created to address the specific care and treatment needs associated with these medications. The facility's policy indicated that residents and their representatives should participate in the development and implementation of person-centered care plans, but this was not followed in this case. A review of the resident's clinical records and physician's orders confirmed the ongoing use of these medications. During an interview, the Director of Nursing acknowledged that a care plan addressing the resident's needs related to anticoagulant, antiplatelet, and diuretic use was not developed and confirmed that it should have been. This omission was identified during a review of 35 residents, with this specific deficiency noted for one resident.
Plan Of Correction
Resident 9's comprehensive care plans were updated to reflect her care needs related to her use of anticoagulant, antiplatelet, and diuretic medications. Any resident who uses anticoagulant medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use anticoagulant medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their anticoagulant use. Any resident who uses antiplatelet medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use antiplatelet medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their antiplatelet use. Any resident who uses diuretic medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use diuretic medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their diuretic use. Licensed Nursing Staff, including Agency Licensed Staff, re-educated on the importance of creating an individualized, person-centered plan of care for residents including care needs for residents who use anticoagulant medications, who use antiplatelet medications, and who use diuretic medications. Interdisciplinary Care Plan Team will continue to review care plans upon resident admissions, at regularly scheduled care plan conferences, and as needed to ensure individualized, person-centered care needs are included and up to date. The Director of Nursing/designee will audit care plans for residents who use anticoagulant medications, who use antiplatelet medications, and who use diuretic medications to be sure these medications are addressed in their care plans weekly times ten weeks and then monthly times four months. These will then be reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times seven months or until substantial compliance is noted.