Failure to Care Plan Anticoagulant Use for Resident with Cerebral Infarct
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the use of the anticoagulant medication rivaroxaban for one resident with a history of cerebral infarct and severely impaired cognition. Despite physician orders and medication administration records confirming the resident was receiving rivaroxaban daily, the care plan did not include any interventions or monitoring related to anticoagulant therapy. Multiple staff interviews revealed that the omission was due to oversight by the MDS nurse and backup staff responsible for care planning, and that the care plan was not updated to reflect the resident's anticoagulant use. Observations and record reviews confirmed that the resident was confused and unable to answer questions, and that there was no visible bruising or bleeding at the time of observation. Staff acknowledged that the lack of a care plan for anticoagulant use could result in other staff, such as CNAs, not being aware of the need to monitor for side effects like bruising or bleeding. Facility policy required care plan revisions upon status change, but this process was not followed in this case, resulting in the deficiency.