Failure to Develop Individualized Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop individualized care plans addressing anticoagulant therapy for two residents. For one resident, the quarterly MDS assessment indicated cognitive impairment and the need for assistance with care, as well as an active order for warfarin to treat atrial fibrillation. Despite these needs, there was no documented evidence of a care plan related to anticoagulant therapy for this resident, as confirmed by the Director of Nursing. Similarly, another resident, who was cognitively intact and required staff assistance for daily care, had diagnoses including heart failure and was also receiving warfarin per physician's orders. The Assistant Director of Nursing confirmed that this resident's care plan did not address care and treatment needs related to anticoagulant medication use. These findings were based on a review of facility policy, clinical records, and staff interviews.