Failure to Hold Anticoagulant as Ordered Prior to Procedure
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order to hold Eliquis, an anticoagulant, for a resident scheduled for a medical procedure. The physician's order specified that Eliquis should be held from the morning of 3/22/25 until the afternoon of 3/24/25 due to a planned wart removal procedure. Despite this order, the medication administration record showed that Eliquis was administered to the resident on the evening of 3/23/25. The DON confirmed that the RN gave the medication during the hold period, only realizing the error when charting the medication. This error led to the cancellation and rescheduling of the resident's medical procedure and required the medication to be held again prior to the rescheduled procedure. The resident involved had a history of non-ST elevation myocardial infarction and was prescribed Eliquis as a blood thinner. The failure to adhere to the hold order was identified through clinical record review and staff interviews.