Failure to Develop Care Plan for Anticoagulant Medication
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan for a resident who was prescribed an anticoagulant medication, apixaban, for atrial fibrillation. The resident was admitted with a physician's order for apixaban, and the medical record confirmed the resident had the capacity to understand and make decisions. Despite this, a review of the resident's medical record did not show any care plan addressing the use of the anticoagulant medication. Interviews with facility staff, including an RN, LVN, the Medical Records Director (MRD), the MDS Coordinator, and the Director of Nursing (DON), confirmed that no care plan was developed for the anticoagulant medication. The RN verified the existence of the physician's order but stated she was not responsible for developing care plans for anticoagulant use upon admission. The LVN emphasized the importance of having a care plan for anticoagulant medications to outline goals and interventions such as monitoring for side effects and reassessment of outcomes. Further interviews revealed that the MRD was responsible for auditing new admission charts for medication entries and baseline assessments, but the ADON and MDS Coordinator were responsible for reviewing and initiating care plans for medications. The MDS Coordinator confirmed that a care plan for anticoagulant use should have been initiated as soon as possible and acknowledged its absence in the resident's record. The DON was informed and acknowledged the findings.