Failure to Transcribe and Administer Prescribed Anticoagulant Medication
Penalty
Summary
A deficiency occurred when the facility failed to transcribe and administer a prescribed anticoagulant medication, apixaban/Eliquis, for a resident who was admitted from a general acute care hospital. The resident had a documented history of atrial fibrillation and was prescribed apixaban/Eliquis 5 mg twice daily as part of the hospital physician's transfer orders. Upon review, it was found that the medication was not entered into the facility's Medication Administration Record (MAR) and was not administered during the resident's stay. Interviews with nursing staff revealed that the admitting nurse was responsible for reviewing and reconciling the medication list from the transferring hospital, but the apixaban/Eliquis order was omitted during transcription. The pharmacy did not receive an order for the medication and therefore did not dispense it. The attending physician confirmed that the resident was supposed to be on an anticoagulant and had approved the existing transfer medications, but the omission was not identified until after the resident's transfer to another facility. Facility policy required that all new admission charts be audited within 72 hours and that medication reconciliation be performed to ensure all prescribed medications are accurately transcribed and administered. Despite these policies, the omission of apixaban/Eliquis was not detected during the admission process or subsequent chart audits, resulting in the resident missing prescribed doses of a high-risk medication.