Baseline Care Plan Omitted Resident’s Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident’s baseline care plan reflected the resident’s current medications at the time of admission. The resident was admitted with diagnoses including ST elevation myocardial infarction (STEMI), congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. The hospital discharge summary documented that the resident’s anticoagulant therapy had been changed from Eliquis to Xarelto, with a loading dose of Xarelto 15 mg twice daily starting on 12/7/2025 and a planned transition to Xarelto 20 mg daily on 12/29/2025. Upon admission, the physician orders at the facility included Xarelto as an anticoagulant medication. Record review showed that the resident’s baseline care plan, dated 12/10/2025, did not list anticoagulant medication among the resident’s current medications and did not include any care plan addressing anticoagulant therapy. During an interview, the DON confirmed that the resident was taking Xarelto at the time of admission and acknowledged that the anticoagulant medication should have been included in the baseline care plan. This omission occurred despite the requirement that the baseline care plan, provided within 48 hours of admission, detail the components of care the facility intends to provide, including current medications.
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