Failure to Individualize and Communicate Anticoagulant and Cardiac Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, individualized care plan addressing anticoagulant therapy and cardiac management for a resident with extensive cardiac history and long-term anticoagulation. The resident had diagnoses including acute diastolic congestive heart failure, prior TIA, cerebral infarction, atrial fibrillation, coronary artery disease, ischemic cardiomyopathy, prior STEMI, and long-term anticoagulation. Physician orders included warfarin 2 mg nightly and specific monitoring for signs and symptoms of bleeding such as discolored urine, black tarry stools, sudden severe headache, nausea, vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status or vital signs, shortness of breath, and nosebleeds. The comprehensive care plan, reviewed on 3/9/26, lacked individualized cardiac management interventions and goals, and only contained a generic problem for potential alteration in blood formation and coagulation related to anticoagulant use, without detailed, individualized cardiac monitoring interventions. The facility also failed to ensure that care plan interventions related to anticoagulant therapy were effectively communicated to direct care staff. The resident’s Kardex and nursing assistant care guide sheets did not include interventions or instructions for monitoring or reporting signs and symptoms of bleeding or indicate that the resident was on blood-thinning medication. Nursing assistants reported they were unaware which residents were on anticoagulants and did not know the specific signs and symptoms of bleeding they should observe and report. One nursing assistant stated she did not know what a tarry stool was and did not report every bruise, assuming nursing staff could see them, and another stated she might delay reporting bruising or weakness until the end of the shift because she did not recognize them as significant. Events preceding the deficiency included the resident’s hospitalization for gastrointestinal bleeding, with an ED note identifying a suspected GI source of anemia and reference to dark stools that the resident himself did not witness because he used a bedpan managed by staff. The resident reported that a male staff member had informed him of dark stools a couple of days before hospitalization and that he assumed staff were monitoring this condition. Facility leadership, including the nurse manager and DON, confirmed that the Kardex and care guides did not contain instructions for monitoring or reporting bleeding for residents on anticoagulants and that the resident’s care plan lacked individualized interventions for monitoring and responding to cardiac symptoms such as chest pain and shortness of breath. The facility’s own care planning policy required a person-centered, individualized comprehensive care plan used by staff to guide daily care and updated as the resident’s condition changed, which was not met in this case.
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