Failure to Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that addressed all of a resident’s needs, specifically the use and management of anticoagulant therapy. Facility policy dated 12/2/25 required a comprehensive care plan for each resident, including measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs. One resident, admitted on 12/27/25 with diagnoses including atrial fibrillation, peripheral vascular disease, and pain, had a physician’s order dated 12/28/25 for Rivaroxaban 15 mg once daily. Review of this resident’s comprehensive care plan showed no care plan addressing the anticoagulant medication or how to manage anticoagulant therapy. In a telephone interview, the Social Worker confirmed that the comprehensive care plan did not include a care plan for anticoagulant use and stated that such a care plan should have been initiated for this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
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