Failure to Develop and Implement Care Plans for Residents on Blood Thinners
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for two residents who were prescribed blood thinner medications. For one resident with diagnoses including deep vein thrombosis (DVT), hypertension, and mobility issues, there was no care plan in place to monitor for potential side effects or risks associated with apixaban, a blood thinner prescribed upon admission. Licensed nursing staff confirmed that there were no orders or documentation for monitoring side effects such as bleeding, and that this monitoring was essential due to the serious complications that could arise from the medication. A review of the facility's policy and procedure for comprehensive care planning indicated that care plans should incorporate identified problem areas, risk factors, and targeted interventions. However, interviews with both nursing staff and the Director of Nursing (DON) confirmed that these procedures were not followed for the resident on apixaban, as no care plan or monitoring orders were present in the medical record. The DON acknowledged that staff were expected to monitor for bleeding each shift and check for signs in the mouth, urine, and stool, but this was not documented or implemented. Similarly, another resident with multiple chronic conditions, including COPD, heart failure, and diabetes with chronic kidney disease, was prescribed both aspirin and Eliquis for DVT prophylaxis. Despite active orders for these blood thinners, there was no corresponding care plan developed. Nursing staff and the DON confirmed the absence of a care plan and recognized the importance of care planning as a guiding tool for providing person-centered care and coordinating services. The facility's policy required comprehensive care plans to address all medical, physical, and psychosocial needs, but this was not done for the residents in question.