Failure to Transcribe and Administer Prescribed Anticoagulant Following Hospital Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical record was complete and accurate by not transcribing a prescribed medication, apixaban/Eliquis, from the hospital transfer orders into the facility's records. The resident, who had a history of atrial fibrillation and was prescribed apixaban/Eliquis 5 mg twice daily, was admitted from a general acute care hospital with clear physician orders for this anticoagulant. However, upon review, there was no entry for apixaban/Eliquis in the resident's order summary report or medication administration record (MAR), and no documentation that the medication was 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 facility, but the medication was not transcribed or administered. The LVN assigned to the resident did not recall seeing an order for a blood thinner and did not administer one. The pharmacy supervisor confirmed that the pharmacy did not receive an order for apixaban/Eliquis and therefore did not dispense it. The RN supervisor acknowledged that the medication reconciliation was not completed due to a shift change, and the resident was transferred to another facility within two days, further complicating the process. The attending physician stated that he had approved the existing medications from the hospital transfer orders, including the anticoagulant, but the omission occurred during the transcription and reconciliation process. The DON confirmed that the medication should have been included in the MAR and administered as ordered. Facility policy required accurate medication reconciliation upon admission, but this process was not followed, resulting in an incomplete and inaccurate medical record for the resident.