Failure to Include Anticoagulation Management in Baseline Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for a resident. Facility policy titled “Care Plans - Baseline,” revised April 24, 2025, required that baseline care plans include instructions needed to provide effective, person-centered care and specified that they must contain initial goals based on admission orders and physician orders. For one resident, the baseline care plan did not include a care area addressing the use of anticoagulation medication or monitoring for side effects, despite existing physician orders and the resident’s clinical condition. Clinical record review showed that the resident had diagnoses including a fracture of the neck of the left femur and aftercare following joint replacement surgery, and had been admitted from the hospital after surgical repair of a hip fracture. Physician orders for this resident included enoxaparin sodium administered twice daily. Review of the resident’s baseline care plan did not reveal any care area related to anticoagulant use or monitoring for side effects. In an interview, the Nursing Home Administrator and DON confirmed that the resident’s care plan lacked a care area for anticoagulation medication use and side effect monitoring and acknowledged that it was the facility’s expectation that resident care plans be accurate.
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