Inaccurate Care Plans for Anticoagulant and Antiplatelet Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents reviewed. Specifically, the care plans for both residents inaccurately included anticoagulant therapy, despite there being no physician order or recommendation for such therapy. Instead, both residents were prescribed and receiving antiplatelet therapy (Aspirin), which was not reflected in their care plans. The care plans also included interventions related to monitoring for anticoagulant complications, which were not relevant to the residents' actual medication regimens. For one resident, a female with multiple complex diagnoses including senile degeneration of the brain, atrial fibrillation, and polycythemia vera, the care plan was initiated and revised to state she was on anticoagulant therapy, with goals and interventions related to anticoagulant use. However, review of her medical orders and assessments confirmed she was only receiving antiplatelet therapy and had no orders for anticoagulants. The resident was observed to have severe cognitive impairment and was unable to participate in conversation or confirm her care plan details. A second resident, also a female with a history of cerebral infarction, muscle weakness, and other chronic conditions, had a care plan similarly indicating anticoagulant therapy, with associated goals and interventions. Her medical records showed she was only prescribed antiplatelet therapy, with no anticoagulant orders. Staff interviews confirmed that care plans are used as the basis for resident care, and that inaccuracies or contradictions in care plans, physician orders, or assessments should be cross-referenced and corrected. The deficiency was attributed to incorrect focus areas being triggered in the care planning process, resulting in care plans that did not accurately reflect the residents' current medication regimens.