Failure to Develop Comprehensive Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents receiving anticoagulant therapy, as required by facility policy. Specifically, three residents with physician orders for anticoagulant medications such as Eliquis, Apixaban, and Plavix did not have corresponding care plans addressing this therapy. Medical record reviews for these residents showed that despite their diagnoses—including pneumonia, surgical amputation, fractures, malignancy, and chronic venous hypertension—and documented cognitive status, there were no care plans in place to address the management and monitoring of their anticoagulant use. Interviews with the MDS Registered Nurse confirmed the absence of anticoagulant therapy care plans for each of the affected residents and acknowledged that such care plans should have been developed. The facility's own policy, revised in February 2025, requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident to meet their physical, psychosocial, and functional needs. This deficiency was identified during a complaint investigation and affected three out of ten residents reviewed for care plans, with a facility census of 124.