Failure to Maintain Comprehensive Care Plan for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's care plan was comprehensive and accurately reflected all physician orders and the resident's needs. A resident with diagnoses including heart failure and pain was admitted and had a physician order for weekly skin checks and for administration of apixaban, an anticoagulant, twice daily. The resident's annual MDS indicated moderate cognitive impairment. On one occasion, a nurse was notified that the resident had a long, dark bruise on the underside of the right breast, which the resident could not explain and did not report pain. Staff confirmed that the resident was on anticoagulant therapy and bruised easily. Although the care plan noted anticoagulant therapy and directed staff to report and document abnormalities such as bruising, it was confirmed by the Director of Nursing Services that the physician order for anticoagulant medication was not included in the care plan. The care plan was not updated after the bruise was discovered, despite staff notification and risk management initiation.