Failure to Monitor Anticoagulant Side Effects as Directed in Care Plans
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not providing appropriate monitoring for residents prescribed Eliquis, an anticoagulant. Four residents were identified as receiving Eliquis without documented monitoring for side effects such as bleeding or bruising, despite care plans indicating that such monitoring should occur at least daily. The care plans for these residents specifically included interventions to monitor for signs of active bleeding, but there was no evidence in the medical records, Medication Administration Records (MARs), or Treatment Administration Records (TARs) that this monitoring was being performed or documented. Interviews with facility staff revealed that the transition to a new electronic charting system resulted in the removal of prompts or reminders for staff to monitor for medication side effects. Certified Nursing Assistants (CNAs) and nursing staff reported that previous printed materials, which included monitoring instructions, were no longer available after the system change. Staff members, including LPNs and RN supervisors, acknowledged that monitoring for bleeding should be in place for residents on blood thinners, but confirmed that such monitoring was not being documented or ordered in the current system. The Director of Nursing (DON) and Director of Clinical Operations stated that monitoring information was only present in the care plan and not in active orders or documentation, and believed that documentation was not required beyond the care plan. Additionally, the facility did not have a policy for anticoagulation or high-risk medication monitoring. The Director of Clinical Operations stated that the pharmacy advised monitoring was not necessary for Eliquis, and that it was sufficient for the information to be in the care plan. However, surveyors clarified that daily monitoring should be documented as indicated in the care plans. Despite being informed of the lack of monitoring documentation, facility leadership did not provide further explanation or evidence that monitoring was occurring for the affected residents.