Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
A resident with a diagnosis of peripheral vascular disease was admitted to the facility and prescribed Clopidogrel Bisulfate, an anticoagulant, for clot prevention. The April 2025 Medication Administration Record (MAR) indicated the resident was to receive 75mg of the medication daily at bedtime. Despite the known side effects of Clopidogrel, such as collection of blood under the skin and deep, dark purple bruises, there was no evidence in the medical record that adverse side effects were being monitored. During an interview, the resident displayed multiple bruises on both arms and was unaware of their origin. Staff interviews revealed that skin checks were only completed weekly, and no bruising had been documented. Additionally, a new skin tear was noted by staff, but there was no documentation of bruising or monitoring for side effects related to the anticoagulant in the resident's chart. Further review and interviews with nursing staff and clinical leadership confirmed the absence of any orders or documentation for monitoring the resident for adverse effects of anticoagulant therapy. Staff acknowledged that monitoring for side effects should have been conducted and documented each shift, but this was not done. The lack of monitoring and documentation placed the resident at risk for medication complications associated with anticoagulant use.