Inaccurate Change in Condition Documentation for Resident on Antiplatelet Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for one resident in accordance with its own charting and documentation policy. The facility’s policy, revised in July 2017, requires that all services provided, progress toward care plan goals, and any changes in a resident’s medical, physical, functional, or psychosocial condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team. For a resident with severe cognitive impairment, an eINTERACT Change in Condition Evaluation V5 dated 1/12/26 documented an unwitnessed fall. On this form, the question regarding whether the resident was on another anticoagulant (direct thrombin inhibitor or platelet inhibitor) was answered “no.” Medical record review showed that, as of 12/25/25, there was a physician’s order for clopidogrel bisulfate 75 mg orally once daily for coronary artery disease, which is an antiplatelet medication used to prevent blood clots. During interviews with RN 2 and the DON, both confirmed that the resident was receiving clopidogrel and that the nurse completing the change in condition evaluation should have answered “yes” to the anticoagulant/antiplatelet question to ensure accurate documentation. The inaccurate response on the change in condition form constituted a failure to accurately document the resident’s status in the medical record as required by facility policy.
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