Failure to Include Anticoagulant Monitoring in Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan addressed the management and monitoring of anticoagulant therapy. The resident, who was cognitively intact and had diagnoses including atrial fibrillation, acute embolism and thrombosis of deep veins, and heart failure, was receiving varying doses of warfarin for atrial fibrillation. Despite these conditions and the use of anticoagulant medication, the resident's care plan did not include any mention of anticoagulant use, increased risk for bleeding, or the need for monitoring side effects associated with anticoagulant therapy. Interviews with the nurse manager and the Director of Nursing confirmed that the care plan lacked a focus area related to anticoagulant therapy or instructions for monitoring side effects such as bleeding or bruising. The facility's own anticoagulation protocol required staff to assess for adverse drug reactions and monitor for complications like excessive bruising or bleeding, but these requirements were not reflected in the resident's care plan. Additionally, the facility was unable to provide a care plan policy when requested.