Failure to Administer Prescribed Anticoagulant for Resident with Atrial Fibrillation
Penalty
Summary
A deficiency occurred when a resident admitted for post-acute care with a diagnosis of atrial fibrillation (Afib) did not receive the prescribed anticoagulant medication, Eliquis, as indicated in her hospital discharge records and multiple provider notes. Despite documentation from the hospital and repeated references in progress notes by nurse practitioners, physician assistants, and physicians that the resident was to be on Eliquis for Afib and deep vein thrombosis (DVT) prophylaxis, there was no corresponding physician order or administration of Eliquis during the resident's stay at the facility. The March Medication Administration Record (MAR) confirmed that Eliquis was never given, and the medication was not listed in the facility's physician orders. The resident's care plan acknowledged her altered cardiovascular status, including Afib, hypertension, and hyperlipidemia. Hospital records prior to admission to the facility indicated that Eliquis was to be restarted after stopping heparin, and the resident was cleared for discharge with instructions for follow-up related to paroxysmal atrial fibrillation. Despite this, the facility failed to ensure the continuation of Eliquis therapy, and the oversight was not identified by the pharmacist during a medication regimen review or by the clinical team, who continued to document that the resident was on Eliquis based on previous notes rather than verifying actual orders and administration. The deficiency became evident when the resident experienced a syncopal episode with hypoxia during occupational therapy, leading to her transfer to the hospital. Hospital records from this subsequent admission revealed a diagnosis of bilateral pulmonary embolism, for which a mechanical thrombectomy was performed. Interviews with facility staff confirmed that the absence of Eliquis was not recognized, and documentation errors perpetuated the assumption that the resident was receiving the medication.