Failure to Administer Ordered Anticoagulant After Pulmonary Embolism Diagnosis
Penalty
Summary
A deficiency occurred when a resident with a history of chronic atrial fibrillation, heart failure, cerebrovascular disease, and chronic obstructive pulmonary disease was not administered an ordered anticoagulant medication (Eliquis) following a new diagnosis of pulmonary embolism. The resident had recently returned from the hospital, where conservative management with Eliquis was recommended due to a history of hematuria with the medication. Upon return to the facility, an order for Eliquis 5 mg twice daily was placed. Despite the order, the bedtime dose of Eliquis was not administered on the day of the resident's return because the medication was reportedly not available and was being delivered from the pharmacy. However, the Director of Nursing later confirmed that Eliquis was available in the facility's contingency medication box, but the nurse did not retrieve it. This failure to administer the medication as ordered was confirmed through medical record review and staff interview.
Plan Of Correction
The Facility will continue to ensure anticoagulants are administered as ordered. Resident #76 continues to reside at the facility. The DON reported missing doses to PCP, with no further recommendations needed. Nurse identified as marking medication as unavailable and not given was reeducated regarding the pharmacy contingency box that allows nurses to pull medications without waiting on pharmacy to deliver. An initial audit of residents on anticoagulant medication was conducted by the DON on 4/1/2025, ensuring medication was given timely and as ordered. No negative findings were noted. By 4/17/2025, licensed nurses will be reeducated by the DON on the pharmacy contingency box, ensuring medications such as anticoagulants are given timely and as ordered. Weekly for 2 weeks or as directed by the QA committee, the DON will randomly review 5 residents who are on an anticoagulant, ensuring they are receiving their medications as prescribed. Negative findings will be corrected immediately by reporting findings to the PCP for recommendations and reeducating the licensed nurse. Negative findings will be reported to the QA committee for review. The Administrator will ensure the completion of the weekly audits. The DON is responsible for the ongoing compliance.