Failure to Monitor Anticoagulant Therapy and Maintain Comprehensive Care Plan
Penalty
Summary
The facility failed to monitor the use of anticoagulant medication for one resident who was admitted with diagnoses including paroxysmal atrial fibrillation, coronary artery disease, and congestive heart failure. The resident was prescribed Apixaban, an anticoagulant, but the care plan related to this medication was not comprehensive or person-centered. Specifically, the care plan lacked information on monitoring for side effects such as bleeding, and there was no evidence that the resident was being monitored for these side effects as required. Interviews with the Quality Assurance Nurse and the Director of Nursing confirmed that the care plan did not include necessary details for monitoring the resident for adverse effects of anticoagulant therapy. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the resident in question. The deficiency was identified through review of the resident's records, care plan, medication administration record, and physician's orders.
Plan Of Correction
F755 - Pharmacy Services/Pharmacist/Records How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 6/2/25, the Quality Assurance Nurse (QAN) included the monitoring for the anticoagulant medication for Resident 45. (Exhibit #20) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/17/25, the Director of Staff Development (DSD) and QAN reviewed the list of residents on anticoagulant medication to ensure monitoring for side effects, including bleeding, was included. (Exhibit #21) - No other resident affected of the same deficient practice. What measures put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Comprehensive Care Plans" dated 12/19/2022. (Exhibit #22) - Beginning on 6/17/25, the QAN will review the care plan and electronic medication record (eMAR) weekly for three months of those residents who received anticoagulant medication to ensure monitoring for side effects including bleeding was indicated. (Exhibit #23) - Starting on 6/17/25, the QAN will report to the administrator for any non-compliance. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The QAN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025