Failure to Care Plan for Respiratory Conditions and Anticoagulant Use
Penalty
Summary
The deficiency involves the facility’s failure to develop individualized, person-centered comprehensive care plans addressing significant clinical conditions and treatments for two residents. For the first resident, who had chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and recurrent pneumonia including MRSA pneumonia, the quarterly MDS documented these respiratory diagnoses. However, review of the active comprehensive care plan last updated on 09/30/25 showed no care plan addressing COPD, respiratory failure, or pneumonia, despite ongoing respiratory issues. Physician orders since September 2025 showed daily and PRN medications for COPD and chronic respiratory symptoms and multiple courses of antibiotics for pneumonia, and multiple physician progress notes documented respiratory complaints, hospitalizations for pneumonia, dyspnea, and continued aggressive treatment. Further documentation for this resident included a pulmonology consult following a recent hospitalization for right lower lobe pneumonia, noting ongoing chest congestion, cough, wheezing, and possible bronchiectasis with mucus impaction, with a recommendation to continue antibiotics. During an interview and observation, the resident had a current cough and slightly labored breathing and reported ongoing respiratory issues. The Medical Director described the resident’s COPD as severe and chronic, requiring frequent monitoring and respiratory symptom management by staff. Despite these documented conditions and treatments, there was no corresponding respiratory care plan in the resident’s comprehensive care plan. The second resident had diagnoses including myocardial infarction and chronic atrial fibrillation and was receiving an anticoagulant, Apixaban 2.5 mg by mouth twice daily, for history of myocardial infarction and deep vein thrombosis prevention. The quarterly MDS assessment indicated anticoagulant use, and the MAR confirmed that the resident consistently received Apixaban as ordered from 01/01/2026 through 03/31/2026. However, the active comprehensive care plan, initiated in October 2025 and last revised in January 2026, did not contain any focus area or interventions related to anticoagulant therapy. Interviews with the Informatics Nurse, DON, and Administrator confirmed that anticoagulant medications are considered high-risk and should be care planned, and they could not explain why this resident’s anticoagulant use was not addressed in the care plan.
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