Failure to Monitor for Bleeding in Resident on Anticoagulant
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not monitoring for active bleeding or bruising in a resident receiving an anticoagulant. The resident had diagnoses including chronic kidney disease, chronic diastolic congestive heart failure, and atrial fibrillation, and was prescribed Apixaban (Eliquis) for atrial fibrillation. The care plan specifically identified the resident as being at risk for abnormal bleeding and/or bruising due to anticoagulant use, with interventions requiring monitoring for signs of active or internal bleeding and prompt physician notification if such symptoms were observed. Despite these documented orders and care plan interventions, a review of the resident's medical record revealed no evidence that monitoring for active bleeding, bruising, or symptoms of internal bleeding was performed or documented. This lack of documentation was confirmed during an interview with the facility's clinical operations/regional support staff, who acknowledged the absence of monitoring records for the resident in question.