Failure to Care Plan for Residents on Blood-Thinning Medications
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plans addressing the use of blood‑thinning medications for three residents receiving antiplatelet or anticoagulant therapy. For one resident with a history of stroke and dysphagia who received clopidogrel via G‑tube and aspirin via J‑tube, the admission MDS documented antiplatelet use and the Treatment Administration Record (TAR) contained physician‑ordered monitoring related to blood‑thinning medications. However, the comprehensive care plan in effect at the time of survey did not identify any problem, goal, or interventions related to blood‑thinner use, did not identify the resident as being at risk for bleeding, and did not include interventions to manage or mitigate bleeding risk. The Kardex and requested care guide also did not identify the resident’s use of blood‑thinning medications. A second resident with atrial fibrillation had an admission MDS documenting anticoagulant use and a physician’s order for apixaban twice daily. The FDA‑approved labeling for apixaban notes increased risk of serious, potentially fatal bleeding and lists signs and symptoms of blood loss. The January TAR showed physician‑ordered monitoring interventions associated with blood‑thinning medications, but the comprehensive care plan did not include any problem, goal, or interventions related to anticoagulant therapy. This resident was not identified in the care plan as being at risk for bleeding, and there were no individualized interventions addressing management or mitigation of bleeding risk. The Kardex did not identify the resident’s use of blood‑thinning medications, and the requested care guide was not provided. A third resident with an infection and inflammatory reaction due to an internal joint prosthesis of the left knee had an admission MDS documenting anticoagulant use and a physician’s order for daily enoxaparin injections. The FDA‑approved labeling for enoxaparin states it should be used with extreme caution in conditions with increased risk of hemorrhage. The January TAR again showed physician‑ordered monitoring interventions related to blood‑thinning medications, but the comprehensive care plan did not identify any problem, goal, or interventions related to anticoagulant therapy or bleeding risk. The Kardex and an undated care guide did not identify the resident’s use of blood‑thinning medications. During interview, this resident reported receiving a daily blood‑thinner injection in the abdomen and experiencing bruising at the injection site. Staff interviews revealed that NAs rely on care guides and Kardexes, which did not list blood‑thinner use, and that the nurse manager and DON were unaware or unable to explain the need to address blood‑thinning medications and associated bleeding risk in the care plans. The facility’s care planning policy lacked specific guidance requiring identification and care planning of high‑risk medications and routes, and therefore did not ensure foreseeable risks such as bleeding from blood‑thinning medications were addressed through individualized care plan interventions.
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