Failure to Monitor for Bleeding in Resident on Anticoagulants
Penalty
Summary
Facility staff failed to monitor a resident for signs and symptoms of bleeding and bruising while the resident was receiving both aspirin and Eliquis for stroke prophylaxis. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction and lacked capacity to make medical decisions, was identified as high risk for bleeding and bruising due to these medications. The care plan specifically required staff to monitor and document any signs of bleeding every shift. Despite these requirements, a review of the Medication Administration Record for the month showed that staff did not document monitoring for bleeding or bruising between the first and twenty-fourth of the month. The Director of Nursing confirmed that the facility did not actively monitor the resident for adverse effects related to anticoagulant therapy, which was contrary to both the resident's care plan and the facility's own anticoagulation protocol.