Failure to Update Care Plan After Initiation of Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was started on an anticoagulant medication (Eliquis) for chronic atrial fibrillation. Despite the new physician order for the anticoagulant, the resident's care plan was not updated to include this medication or address associated risks such as bleeding and bruising. Interviews with facility staff, including the MDS Coordinator and DON, confirmed that the omission was an oversight and that the care plan should have been revised to reflect the new medication and its monitoring requirements. Record review showed that the resident had multiple diagnoses, including pulmonary fibrosis, congestive heart failure, hypertension, chronic kidney disease, and type 2 diabetes. The facility's policy required care plan updates upon any change in resident status, including new medications, but this process was not followed. Staff interviews revealed confusion about responsibility for care plan audits, with Medical Records staff stating they did not audit care plans and were unsure who was responsible. This lack of care plan revision after a significant medication change constituted the identified deficiency.