Failure to Develop Comprehensive Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing anticoagulant therapy and related safety precautions for a resident with atrial fibrillation and a hip fracture. The resident, who was moderately cognitively impaired, was prescribed Eliquis 2.5 mg twice daily for atrial fibrillation. Despite the ongoing use of this anticoagulant, the resident's care plan did not include individualized documentation of pharmacological and non-pharmacological interventions, nor did it address potential side effects or adverse effects associated with the medication. Interviews with nursing staff confirmed that the care plan lacked evidence of monitoring for anticoagulation therapy, such as observing for symptoms like dark stools, bruising, abnormal bleeding, or severe paleness. The assistant director of nursing also acknowledged that the care plan should have included interventions specific to anticoagulant use and its side effects. Review of facility policy indicated that care plans were required to include measurable objectives, timeframes, and ongoing assessments, but these elements were missing in the resident's care plan regarding anticoagulant therapy.