Failure to Monitor and Document Medication Side Effects and Efficacy
Penalty
Summary
The facility failed to ensure that two residents were properly monitored for medication side effects and efficacy, resulting in a deficiency. For one resident with severe cognitive impairment and multiple diagnoses including atrial fibrillation, depression, and anxiety, physician orders required monitoring for signs and symptoms of bleeding due to anticoagulant therapy (Eliquis), monitoring of sleep hours for Trazadone, and documentation of episodes of physical restlessness for Buspar. These monitoring orders were not transcribed onto the Medication Administration Record (MAR) by the responsible RN, and as a result, no monitoring or documentation was completed for the specified period. The LVN confirmed the absence of required monitoring documentation, and the RN acknowledged missing the transcription of these orders, which prevented nursing staff from implementing the necessary monitoring protocols. Another resident, also with severe cognitive impairment and multiple medical conditions including atrial fibrillation and heart failure, was prescribed Apixaban, an anticoagulant. The resident's care plan included interventions to monitor for side effects and effectiveness of the medication, with instructions to document and report any adverse reactions. However, the MAR showed no documentation of monitoring for anticoagulant side effects during the specified period. The LVN responsible for the resident stated that she did not monitor for side effects because she believed it was only necessary if symptoms appeared, and she was unaware of the care plan's requirement for ongoing monitoring and documentation. The DON confirmed that daily monitoring and documentation for anticoagulant side effects should have been completed as per the care plan and facility policy. Facility policies reviewed indicated that nurses are responsible for carrying out physician orders, including transcribing them onto medication or treatment records and ensuring communication to relevant staff. The policies also required assessment and documentation of anticoagulant therapy, including monitoring for adverse drug reactions. The failure to transcribe, implement, and document physician-ordered monitoring for these residents resulted in a lack of oversight for potential medication side effects and effectiveness, as required by both physician orders and facility policy.