Failure to Include Anticoagulant Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, generalized muscle weakness, need for assistance with personal care, and chronic migraine without aura. Physician orders for this resident included low-dose aspirin for clot prevention and warfarin sodium for cerebral infarction. The baseline care plan, dated several days after admission, documented that the resident had an advance directive of full code, was at risk for falls related to psychotropic medication use, poor balance, and weakness, and had potential for pain. However, the baseline care plan did not address the resident’s use of anticoagulant medication, despite active orders for aspirin and warfarin. During an interview, the DON confirmed that the baseline care plan did not include the use of anticoagulants and acknowledged that the baseline care plan should have been completed within 48 hours of admission, which did not occur.
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