Inaccurate Care Plan for Resident on Antiplatelet Therapy
Penalty
Summary
Facility staff failed to develop an accurate, comprehensive, person-centered care plan for one resident related to the resident’s medication regimen. The resident was admitted with multiple cardiovascular diagnoses, including coronary artery disease, paroxysmal atrial fibrillation, congestive heart failure, and peripheral vascular disease. Physician orders dated 12/16/25 showed the resident was prescribed Clopidogrel Bisulfate 75 mg by mouth in the morning for coronary artery disease, which is an antiplatelet medication. The resident’s MDS dated 05/27/25 documented that the resident was taking an antiplatelet medication and not an anticoagulant. Despite this, the resident’s care plan dated 05/28/25 stated the resident was on anticoagulant medication therapy and at risk from taking blood-thinning medications, inaccurately reflecting the type of medication actually prescribed and administered. During observation and interview on 12/15/25, the resident was noted to have bruising on both hands and reported being on an anticoagulant and bruising easily. In a subsequent interview on 12/19/25, the DON confirmed that the electronic medical record did not show an anticoagulant order, acknowledged that the resident had been care planned for an anticoagulant instead of an antiplatelet, and stated that anticoagulants and antiplatelets are significantly different types of medications.
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