Care Plan Not Updated to Reflect Change in Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to accurately reflect the current anticoagulant medication regimen. Specifically, a resident with a history of hypertension and atrial fibrillation was initially on Coumadin therapy, which was discontinued in January 2025. The resident was subsequently prescribed Eliquis for anticoagulation, as indicated by physician orders dated February 2025. Despite these changes, the care plan continued to reference Coumadin therapy and related monitoring, such as INR and Protime, and was not updated to reflect the new medication regimen. Review of the resident's records showed that two Minimum Data Set (MDS) assessments were completed after the medication change, but the care plan was not revised accordingly. Interviews with facility staff confirmed that the care plan should have been updated during routine quarterly reviews and that nursing staff are responsible for making updates between MDS assessments. The discrepancy was identified during a review of the care plan and physician orders, and staff acknowledged that the care plan did not accurately reflect the resident's current anticoagulant therapy.