Failure to Care Plan for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing anticoagulant therapy for a resident who was receiving Enoxaparin Sodium for DVT prevention. The resident had a history of falling, unspecified dementia, and unspecified anemia, and an MDS assessment showed a BIMS score of 02, indicating severe cognitive impairment. The MDS also documented that the resident was receiving an anticoagulant. A physician order directed daily subcutaneous Enoxaparin Sodium injections for 19 days, and the MAR showed the medication was administered on multiple days in January in the resident’s abdomen. Despite this ongoing anticoagulant therapy, the clinical record and care plan report contained no anticoagulant therapy focus area or anticoagulant-specific interventions, contrary to the facility’s anticoagulation management policy requiring that anticoagulant use be reflected in the care plan. During interviews, a CNA stated that staff rely on the care plan to identify resident-specific needs and that residents on blood thinners require extra caution due to prolonged bleeding and easy bruising, with monitoring for bruising and blood in urine being important. An RN confirmed that staff depend on care plans to identify resident-specific risks and interventions, acknowledged that anticoagulant therapy requires individualized care planning, and verified that there was no anticoagulant-related care planning in the resident’s record. A rehab staff member stated that residents on anticoagulants are at higher risk for bleeding and bruising and that care plans should include monitoring vital signs, symptoms, and blood loss, and coordination among departments to minimize fall risks. The DON stated that care plans are expected to guide staff in implementing fall prevention interventions and to be reviewed and revised after any incident, and confirmed that the resident who experienced a fall while on Enoxaparin had no care plan interventions addressing anticoagulant therapy, which did not meet facility expectations or its care planning and anticoagulation management policies.
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