Failure to Include Anticoagulant Monitoring in Care Plans
Penalty
Summary
The facility failed to ensure that care plans for two residents receiving anticoagulant therapy included management and monitoring for potential side effects, specifically signs of bleeding. One resident, who was cognitively intact and had diagnoses including atrial fibrillation, hypertension, and a history of stroke, was prescribed Eliquis but did not have corresponding care plan interventions or monitoring orders for side effects related to anticoagulant use. Similarly, another resident with severe cognitive impairment, hypertension, diabetes, Alzheimer's disease, and a history of stroke was prescribed warfarin, but their care plan also lacked documentation of anticoagulant use and monitoring for adverse effects. Interviews with facility staff, including a registered nurse case manager, consultant pharmacist, and the director of nursing, confirmed that there was an expectation for monitoring for bruising and bleeding in residents on anticoagulants. However, the care plans and order summaries reviewed did not reflect these practices. Additionally, the facility's policy on anticoagulant use did not address monitoring requirements, contributing to the deficiency.