Failure to Timely Develop Care Plans for Residents on Anticoagulation Therapy
Penalty
Summary
The facility failed to develop and implement timely care plans for anticoagulation therapy for two residents who were prescribed Coumadin (Warfarin) following their admission. Both residents had medical histories that included conditions such as atrial fibrillation, cerebral infarct with hemiplegia/hemiparesis, antiphospholipid syndrome, and transient ischemic attack, and were ordered to receive daily Coumadin with specific instructions for INR monitoring and dose adjustments. Despite these orders and the administration of Coumadin over several weeks, review of the clinical records and resident care plans revealed that neither resident had a care plan addressing anticoagulation therapy or the associated risk for bleeding, as required by facility policy and the Coumadin protocol. Interviews with the DON, Administrator, and an RN confirmed that it was the responsibility of the nursing or MDS team to ensure care plans reflected resident needs and treatment plans, and that comprehensive care plans should be completed within the required timeframe after admission. The facility was unable to provide documentation of care plans for anticoagulant use for either resident and acknowledged that such care plans should have been in place. The reason for the omission could not be identified during the interviews.