Failure to Develop Comprehensive Care Plans for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who were receiving anticoagulant medications. For both residents, the care plans did not include anticoagulant use as a focus area, and there were no documented interventions or dates provided to address this aspect of their care. Record reviews confirmed that both residents had significant cognitive impairments and required substantial to maximal assistance with activities of daily living. Despite these needs and the administration of anticoagulants, their care plans lacked any mention of this medication or related care strategies. Interviews with the MDS Coordinator confirmed that she was responsible for completing care plans and acknowledged the absence of care plans addressing anticoagulant use for both residents. The Director of Nursing also confirmed the importance of comprehensive care plans and recognized that not having them could result in negative outcomes, such as bleeding or bruising. Facility policy requires that comprehensive, person-centered care plans with measurable objectives and timetables be developed and implemented for each resident, but this was not followed in these cases.