Failure to Develop Person-Centered Care Plan for Anticoagulant and Antiplatelet Therapy
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who was prescribed both apixaban (an anticoagulant) and clopidogrel bisulfate (an antiplatelet medication). Despite the resident's medical history, which included Parkinson's disease, atherosclerotic heart disease, and other vein disorders, there was no care plan initiated to address the use of these medications. The resident's records, including the admission record, order summary reports, and comprehensive care plan, did not reflect any individualized plan or interventions related to the administration of apixaban or clopidogrel bisulfate. Interviews with facility staff, including an LVN and the DON, confirmed that no resident-specific care plans were in place for the use of these medications. Both staff members acknowledged that the absence of such care plans meant there were no established goals or interventions to guide care related to the medications, and that this was not in accordance with facility policy. The staff recognized that the resident was at risk for issues such as bruising and skin discoloration, as noted in the resident's skin assessments, but these risks were not addressed in a care plan. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives, timeframes, and interventions based on the resident's needs and conditions. However, the care plans for this resident did not include any information or interventions related to the use of anticoagulant or antiplatelet therapy, despite the resident's moderate cognitive impairment and ongoing use of these medications.