F0656

B

Failure to Incorporate Anticoagulant and Hearing Needs into Comprehensive Care Plans

High Point, North Carolina Survey Completed on 04-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop individualized comprehensive care plans that addressed anticoagulant use and communication needs for multiple residents. For one resident with a pelvic fracture and atrial fibrillation, physician orders showed an ongoing Eliquis 5 mg twice daily order, and the baseline care plan identified a risk for bleeding due to anticoagulant use. The admission MDS confirmed anticoagulant use and intact cognition. However, the comprehensive care plan dated 6/20/25, last revised 2/26/26, did not carry over the baseline intervention regarding bleeding risk from anticoagulant therapy, and there was no focus area for anticoagulant use. The nurse mentor who completed the care plan and the DON both acknowledged that anticoagulant use should have been included and that its omission was an oversight.

A second resident with diagnoses including long-term use of anticoagulants, atrial fibrillation, chronic systolic heart failure, and hypertensive heart and chronic kidney disease had been receiving Eliquis 5 mg twice daily as documented on the MAR from August 2025 through March 2026. The annual and quarterly MDS assessments showed moderate cognitive impairment and anticoagulant use for heart failure. Despite this, the comprehensive care plan dated 2/9/2026 did not include any goals or interventions related to Eliquis or monitoring for high-risk medication use. The nurse mentor responsible for the care plan confirmed the resident was taking Eliquis and stated that, as a high-risk medication, it should have been on the care plan but could not explain its absence. The DON and Administrator both stated they expected high-risk medications such as Eliquis to be included in the care plan but were unable to explain why it was not.

The facility also failed to include communication and hearing-related needs in the comprehensive care plans for three residents with documented hearing impairment. One resident with congestive heart failure and respiratory failure had an admission assessment and baseline care plan indicating bilateral hearing impairment and the need for hearing aids, with the baseline stating the resident would be responsible for keeping up with the hearing aids. The MDS showed moderate cognitive impairment and adequate hearing with hearing aids. However, the comprehensive care plan dated 2/15/26 contained no communication-related care areas or interventions. Observations showed the resident often did not have hearing aids in place, could not reach them independently, and had difficulty hearing staff unless aids were in and staff were close. The MDS Coordinator stated she did not include hearing on the comprehensive care plan if a resident could hear with hearing aids, and the DON indicated she would not expect impaired hearing to be in the regular care plan for an alert and oriented resident, instead relying on standup meetings to communicate such needs.

Two additional residents with heart disease, surgical aftercare for a right knee, and COPD respectively had admission assessments and baseline care plans documenting impaired hearing in both ears and a need for hearing aids, though the baseline care plans for these residents did not specify hearing aid use. Their MDS assessments indicated either intact cognition or moderate cognitive impairment, with adequate or minimally impaired hearing when using hearing aids. For both residents, the comprehensive care plans contained no communication or hearing-related care areas or interventions. For one of these residents, the CAA summary documented that communication was a triggered care area due to some hearing loss even with hearing aids and explicitly stated that communication would be addressed in the care plan, yet it was not. The MDS Coordinator confirmed she completed these care plans and reiterated that she did not include hearing on the comprehensive care plan if the resident could hear with hearing aids. The DON and Administrator provided differing expectations about when impaired hearing should appear on the comprehensive care plan, but both acknowledged reliance on baseline care plans and standup meetings rather than ensuring communication needs were incorporated into the comprehensive care plans.