Failure to Monitor and Document Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of potential side effects for a resident who was receiving Lovenox, an anticoagulant medication. The resident, who had a history of a displaced intertrochanteric fracture of the left femur, anemia, and hyperlipidemia, was prescribed Lovenox injections for DVT prophylaxis. Despite receiving the medication as ordered, there was no documentation in the electronic medical record to indicate that the resident was monitored for signs and symptoms of bleeding, a known risk associated with anticoagulant therapy. During interviews and record reviews, the Director of Nursing confirmed that staff are expected to monitor and document any side effects of Lovenox, including bleeding, in the electronic medical record. However, a review of the resident's Medication Administration Record and electronic medical record revealed no evidence that such monitoring occurred during the period the resident received Lovenox. The facility's policy on high-risk medications, including anticoagulants, requires staff to monitor for adverse consequences and document these observations, but this was not followed in this case.