Failure to Address Anti-Platelet Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident that addressed the use of anti-platelet therapy and associated safety precautions. The resident had a history of transient ischemic attack and cerebral infarction, was moderately cognitively impaired, and required assistance with daily activities. Despite being prescribed clopidogrel bisulfate (Plavix) for myocardial infarction, the resident's care plan did not include interventions or monitoring parameters related to anti-platelet therapy, such as monitoring for signs and symptoms of bleeding or bruising. Interviews with nursing staff confirmed that the care plan lacked necessary identification of interventions and monitoring for the anti-platelet medication, and review of facility policy indicated that care plans should be individualized and comprehensive.