Failure to Care Plan Anticoagulant Therapy for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and interventions for a resident receiving anticoagulant therapy. Record review showed that the resident, an elderly female admitted with a primary diagnosis of cerebral infarction and additional diagnoses including dementia, sepsis, obstructive and reflux uropathy, and acute kidney failure, had a BIMs score of 3 indicating severe cognitive impairment. Medication orders reflected an active prescription for Eliquis (apixaban) 2.5 mg twice daily for clot prevention, started several months prior. However, review of the resident’s care plan, last revised on 12/20/2025, did not show any care plan addressing anticoagulant use. Interviews with facility staff confirmed that a care plan for anticoagulant medication should have been in place. The Regional RN stated there should be a care plan for anticoagulants to help staff identify adverse reactions, with interventions such as daily monitoring and CNA observation of the resident’s skin. The ADON reported she was responsible for parts of the care plan related to acute care, antibiotics, and falls, and described that staff were expected to monitor for bruising and bleeding in residents on anticoagulants as part of their tasks and morning rounds. The Administrator acknowledged that not care planning for medications like anticoagulants posed a risk that residents could receive medications they should not be getting or experience medication interactions. The facility’s Comprehensive Care Planning Policy required development and implementation of a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ identified medical, nursing, mental, and psychosocial needs, but this was not carried out for the resident’s anticoagulant therapy.
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