Failure to Include Anticoagulant Use in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to include the use of an anticoagulant medication, apixaban, on the care plan for a resident. The resident was cognitively intact, with a BIMS score of 15 out of 15, and had diagnoses including chronic obstructive pulmonary disease, benign prostatic hyperplasia, and urinary tract infection. Physician orders and the Medication Administration Record confirmed that the resident was prescribed and received apixaban 5 mg twice daily for a blockage of a blood vessel to the lung. However, review of the care plan revealed no focus area addressing the use of this anticoagulant medication. The Director of Nursing confirmed during an interview that the use of an anticoagulant should have been included in the care plan and stated that the MDS Coordinator is responsible for updating care plans. The current MDS Coordinator had only recently started and was not present when the care plan was developed. Facility policy requires that comprehensive care plans be based on thorough assessments, including the MDS and physician orders, but this was not followed in this instance.