Failure to Develop Care Plans for Anticoagulant Use and Bleeding Risk
Penalty
Summary
The facility failed to develop and implement person-centered care plans addressing anticoagulant use and risk for bleeding for two residents. One resident, a female with a history of atrial fibrillation and anemia, was prescribed anticoagulants (Xarelto and later Pradaxa) following hospitalization for post-surgical knee sepsis. Despite her diagnoses and medication changes, there was no care plan in place to address her anticoagulant therapy or associated bleeding risks, even after a hospital readmission for anemia and complications related to anticoagulant use. Similarly, another resident with a history of stroke, peripheral vascular disease, and blood clots was admitted with an order for Pradaxa, but also lacked a care plan for anticoagulant use or bleeding risk. Interviews with nursing staff and the Director of Nursing revealed that care plans are typically initiated by the MDS Coordinator and updated by various departments, with information communicated to CNAs through reports, Kardex, or other documentation. However, there was no evidence that care plans specific to anticoagulant use or bleeding risk were created or maintained for these residents. Staff were unable to explain the absence of these care plans, and there was inconsistency in how updates were communicated to CNAs, with no set routine for reviewing the Kardex. The facility's own policies require comprehensive care plans based on thorough assessments and incorporation of risk factors, including monitoring for complications related to anticoagulation, but these were not followed for the affected residents.