Failure to Develop Comprehensive Care Plans for Anticoagulant Use and PTSD
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific clinical needs. For one resident who was prescribed apixaban, an anticoagulant, the Medication Administration Record confirmed the medication was started, but the resident’s care plan did not include any reference to anticoagulant use or monitoring for its adverse side effects. Multiple staff interviews and joint record reviews confirmed that the care plan lacked this essential information, despite staff acknowledging that monitoring for side effects should have been included. Another resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) did not have their history of trauma or identified triggers addressed in their care plan. The resident reported discomfort with certain situations due to past traumatic events, but the care plan did not document the PTSD diagnosis or specific interventions related to trauma-informed care. Staff interviews confirmed that the care plan did not reference triggers or trauma history, and staff stated that such information would be a relevant and expected addition.