Failure to Develop Care Plan for Anticoagulant Use and Bleeding Risk
Penalty
Summary
A deficiency was identified when a resident with atrial fibrillation, severe cognitive impairment, and a pacemaker was admitted to the facility while receiving anticoagulant medications, specifically Eliquis and Plavix. Physician orders directed the administration of these medications for atrial fibrillation, and the resident's quarterly MDS assessment confirmed ongoing use of anticoagulants. Despite these factors, the facility failed to develop a comprehensive care plan addressing the use of Eliquis and Plavix and the associated risk of bleeding for this resident. Record review and staff interviews revealed that there was no care plan in place for the risk of bleeding related to anticoagulant use, as required by facility policy. The Director of Nursing and the MDS Coordinator both acknowledged that a care plan should have been created but was not, citing a change in the electronic medical record system and oversight as contributing factors. The facility's care plan policy mandates the development of a person-centered plan of care within seven days of completing the MDS and CAA's, but this was not followed in this case.