Failure to Develop Care Plan for Epistaxis
Penalty
Summary
A deficiency occurred when the facility failed to initiate and develop a care plan to address a resident's diagnosis of epistaxis (nosebleeds) following their readmission from an acute hospital stay. The resident, who had a history of nosebleeds and was being monitored for side effects of anticoagulant and antiplatelet medications, was observed with blood stains on their gown and washcloth. The resident reported frequent nosebleeds, and the Licensed Vocational Nurse confirmed that episodes of nosebleeds had been ongoing since the nurse began working at the facility. Despite these ongoing episodes, there was no documented evidence that a care plan was created to address the resident's epistaxis. Review of the resident's medical record showed multiple progress notes from a Nurse Practitioner documenting episodes of epistaxis on several dates, but no care plan was developed or initiated during this period. The Director of Nursing confirmed that the resident had a history of nosebleeds prior to hospitalization and that a care plan should have been initiated upon readmission to monitor and address the condition. The facility's policy required care plans to be reviewed and revised after significant changes in a resident's condition or upon readmission, but this was not done for the resident's epistaxis.