Failure to Develop and Implement Comprehensive Care Plans for Anticoagulant Use and Fall Prevention
Penalty
Summary
The facility failed to develop and implement comprehensive and person-centered care plans for a resident with multiple medical needs. Specifically, there was no care plan addressing the resident's use of an anticoagulant medication, despite the resident having a diagnosis of atrial fibrillation and an active order for Eliquis. Both the Assistant Director of Nursing and the Director of Nursing confirmed during interviews and record reviews that a care plan for anticoagulant use was not in place, and acknowledged the importance of monitoring for side effects such as discoloration, bleeding, and bruising. Additionally, the facility did not implement injury prevention interventions identified in the resident's fall risk care plan. The resident, who had a history of falls, muscle weakness, hemiplegia, and recent fractures, was assessed as a fall risk and had a care plan intervention for a floor mat to be placed on the left side of the bed. Multiple observations confirmed that the floor mat was not present, and both the resident and staff verified it had not been in place since admission. The DON acknowledged that the intervention was not implemented as required, which did not follow the established care plan.