Failure to Care Plan Anticoagulant Therapy and Diabetes Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents with significant medical needs. For one resident, an older female with a diagnosis of atherosclerotic heart disease and severe cognitive impairment (BIMS score of 4), records showed she had been prescribed Eliquis (apixaban) 2.5 mg orally twice daily for bilateral lower extremity arterial occlusion since February 2024. Despite this ongoing anticoagulant therapy being documented in the medication administration record and order summary, the resident’s care plan revised in September 2024 did not address her blood thinner medication prescription. For another resident, an older male with intact cognition (BIMS score of 15), the history and physical documented a diagnosis of type II diabetes mellitus, but his care plan revised in September 2025 did not address this diagnosis. In interviews, the DON, Administrator, and MDS nurse each stated that the purpose of the care plan is to detail resident needs and guide staff in providing care, and all acknowledged that diagnoses such as diabetes and medications such as anticoagulants should be included in the care plan. They also reported that the MDS nurse is responsible for creating and revising care plans quarterly and as needed, that floor nurses are expected to communicate updates, and that there had been no recent in-services regarding care plans. Facility policy states that the care plan is to be used in developing residents’ daily care routines and must be available to staff responsible for providing care or services.
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