Failure to Update Care Plan for Anticoagulant Side Effect Monitoring
Penalty
Summary
The facility failed to update and implement a comprehensive care plan for a resident receiving anticoagulant therapy. The resident, who had severe cognitive impairment and multiple diagnoses including a history of stroke, DVT, depression, anxiety, dementia, and Alzheimer's disease, was prescribed Eliquis for DVT. The medication order did not include any special instructions or label comments regarding side effect monitoring. Review of the resident's care plan showed it addressed risks related to falls and side effects of psychotropic medications but did not mention anticoagulant use, increased bleeding risk, or the need for monitoring side effects associated with anticoagulant therapy. Interviews with facility staff, including an LPN, DON, MDS nurse, and consultant pharmacist, confirmed that the care plan and EMAR lacked references to anticoagulant use and side effect monitoring. Staff acknowledged that care plans should include instructions for monitoring for bleeding and other side effects when a resident is on anticoagulant therapy. Facility policies also required assessment and monitoring for adverse drug reactions and complications such as bleeding, but these were not reflected in the resident's care plan or EMAR.