Elara Caring

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POC contained the required elements to cover all safety measures to protect against injury, and patient specific interventions and education for 2 of 10 patient records reviewed for plans of care. (Patient #2 & #3) Patient #2 and Patient #3’s POC did not include bleeding safety precautions or teaching on signs and symptoms to report to the physician or SN while taking Eliquis (blood thinner). This failure could place patients at risk of not recognizing symptoms of bleeding and could lead to complications and hospitalization. Findings included: Patient #2: Record review of Patient #2’s POC dated 02/06/26 to 04/06/26 indicated a SOC date of 02/06/26 and indicated she was 80 years old with diagnosis including wedge compression fracture (spinal injury where the front part of a vertebra (bones forming the backbone) collapses, creating a wedge-shaped bone). The POC indicated Patient #2 was ordered skilled nursing visits 1 time a week for 1 week, then 2 times a week for 1 week, then 1 time a week for 7 weeks. Physical Therapy 1 time a week for 1 week. The POC medication list indicated Patient #2 took Eliquis (blood thinner) 5mg, one tablet by mouth 2 times daily. The POC did not include bleeding safety precautions or teaching on signs and symptoms to report to the physician or SN. Record review of an OASIS (assessment) Admission Visit Note Report for Patient #2 dated 02/06/26 indicated Patient #2 had a history of dementia (memory loss), atrial fibrillation (irregular heartbeat) on blood thinner, stroke (occurs when blood flow to the brain is blocked), breast and kidney cancer, progressive weakness, and recurrent falls. During an interview on 02/10/26 at 9:45 a.m., Patient #2 said she still took Eliquis for her heart and took it twice a day. Patient #3: Record review of Patient #3’s POC dated 01/27/26 to 03/27/26 indicated a SOC date of 01/27/26, and indicated she was 76 years old with diagnoses including heart failure (the heart cannot pump enough blood to meet the body’s needs), chronic kidney disease (progressive loss of kidney function), atrial fibrillation (irregular heartbeat), Alzheimer’s disease (gradually destroys memory, thinking skills, and the ability to carry out daily activities), and long term use of anticoagulants (blood thinners). indicated Patient #3 was ordered skilled nursing visits 3 times a week for 1 week, then 2 times a week for 2 weeks, then 1 time a week for 6 weeks. Physical Therapy 1 time a week for 1 week. The POC medication list indicated Patient #3 took Eliquis (blood thinner) 5mg, one tablet by mouth 2 times daily. The POC did not include bleeding safety precautions or teaching on signs and symptoms to report to the physician or SN. During an interview on 02/10/26 at 10:25 a.m., LVN D said the POC was developed by the RN case manager and updated every 60 days, and with changes/as needed. She said the POC should have bleeding precautions if a patient was on Eliquis. She said it was important so the patient would know what to look for. During an interview on 02/11/26 at 8:45 a.m., RN C said the POC was developed by the RN who went out on a new admission. She said the RN would assess and go through all the patient’s medications. She said the POC was updated continually. She said a POC for a patient on Eliquis should include teaching on asking the patient if they were having dark tarry stools (bowels) and provide extensive education regarding bleeding and symptoms. She said symptoms of bleeding included coffee ground emesis (vomit) and dark tarry stools. She said the nurse needed to know so they could contact the doctor if the patient was experiencing symptoms to make sure they weren’t bleeding. She said the nurse should ask if the patient was having nose bleeds or if their eyes were turning red. RN C said bleed precautions would be on the POC and was listed under safety precautions. She said if a patient was on a blood thinner, the POC should have bleeding precautions. She said Patient #2 was on a blood thinner and if the POC did not have bleeding precautions then she (RN C) messed up. She said after the RN completed the POC it went to the care team manager who reviewed it, then went to the doctor for signature after that. She said POCs were audited, but she didn’t know if they were all audited or how often. During an interview on 02/11/26 at 10:00 a.m., the Alternate Administrator said POCs were developed by the RN while in the home then she (Alternate Administrator) reviewed them. She said the POCs were updated with any orders. She said a POC for a patient on Eliquis should include antiplatelet (medications that prevent blood cells from sticking together) precautions. The Alternate Administrator said the POC should include signs and symptoms of bleeding, bleeding precautions, increased bruising, dark black stools, and the patient was to contact the agency, and the agency would notify the doctor for any symptoms of bleeding. She said the agency would draw labs if they needed to as well. She said teaching was important for bleeding precautions to prevent bleeding that could be happening that the patient did not know. She said the agency wanted to ensure the patients were getting taught and knew what to look for. During an interview on 02/11/26 at 10:25 a.m., the Alternate Administrator said the agency had a team that audited 10 charts every quarter. She said the team audited the POCs and everything in the patient record. During an interview on 02/11/26 at 10:27 a.m., the Administrator/DON said the POCs were developed by a RN and updated every 60 days or as needed. He said a patient on Eliquis the POC should include bleeding precautions, instructions on bleeding and what to watch for. He said this was important, so the patient knew what to watch for. He said 10 charts were audited by the quality department and were audited quarterly. The Administrator/DON said after the RN developed the POC it went to the clinical team manager for review. Record review of a Plan of Care and Coordination of Care policy dated 03/04/25 indicated “…will develop a written plan of care for each patient accepted to care/services… The plan of care includes but is not limited to... safety measures to protect against injury… patient specific interventions, and education…” Review of Eliquis instructions dated 09/22/25 and accessed at https://www.drugs.com/eliquis.html on 02/12/26 indicated “...Eliquis is used to lower the risk of stroke or a blood clot… Eliquis increases your risk of severe or fatal bleeding, especially if you take certain medicines at the same time (including some over-the-counter medicines)… Call your doctor at once if you have signs of bleeding such as: swelling, pain, feeling very weak or dizzy, bleeding gums, nosebleeds, heavy menstrual periods or abnormal vaginal bleeding, blood in your urine, bloody or tarry stools, coughing up blood or vomit that looks like coffee grounds, or any bleeding that will not stop. Eliquis should be stopped 24-48 hours prior to any surgery, invasive procedure, or dental work. Tell your surgeon if you are taking Eliquis… Do not stop taking Eliquis unless your doctor tells you to. Stopping suddenly can increase your risk of blood clot or stroke…””