Failure to Accurately Document Anticoagulant Use in Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment reflective of her current status. Specifically, the most recent quarterly MDS assessment did not indicate that the resident, who had a diagnosis of cerebral infarct and severely impaired cognition, was receiving the anticoagulant medication rivaroxaban, despite physician orders and the medication administration record confirming daily administration of the drug. Additionally, the resident's care plan did not include any reference to anticoagulant therapy. Multiple staff interviews confirmed that the omission was an oversight, and the responsible MDS nurses acknowledged that the anticoagulant was not marked on the MDS or included in the care plan. The Director of Nursing, MDS nurses, and the Regional Case Manager all confirmed their roles in the MDS process and acknowledged the error, stating that the facility did not have a specific MDS policy but followed the RAI manual. The resident was observed to be confused and unable to answer questions, with no visible signs of bruising or bleeding. The failure to accurately document the use of anticoagulant medication on the MDS assessment and care plan was identified through record review, staff interviews, and observation.