Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident who was admitted with multiple diagnoses, including a prosthetic heart valve and long-term use of anticoagulants such as Warfarin. Upon review of the resident's medication orders, it was found that there was no care plan addressing the use of Warfarin, specifically regarding potential adverse side effects or necessary monitoring associated with the medication. Interviews with facility staff revealed that while Certified Nursing Assistants relied on the Kardex to identify residents on blood thinners and monitor for signs of bleeding or bruising, there was no formal care plan in place for this resident's anticoagulant therapy. The Nurse Manager confirmed the absence of a care plan for Warfarin use, and the Director of Nursing stated that such medications should be care planned, but this was not reflected in the resident's documentation at the time of review.