Failure to Initiate Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to initiate a care plan addressing anticoagulation medication use for a resident admitted with multiple complex diagnoses, including end stage renal disease, diabetes mellitus, hyperkalemia, dependence on renal dialysis, heart failure, and intellectual disabilities. Medical record review showed that the resident had physician orders for warfarin sodium, an anticoagulant, but the care plan dated after the medication order did not include any interventions or monitoring related to anticoagulant therapy. This omission was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan for anticoagulant use. The deficiency was identified during a complaint investigation and affected one of three residents reviewed for care plans.