Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for side effects of the anticoagulant medication Eliquis. The resident, a cognitively intact female with diagnoses including atrial fibrillation and atherosclerotic heart disease, was prescribed Eliquis for atrial fibrillation and for an infection and inflammatory reaction due to a knee prosthesis. The care plan required staff to monitor and document any adverse reactions to anticoagulant therapy, such as bleeding, bruising, or changes in mental status. However, review of the medication administration record showed no evidence that monitoring for side effects was performed during the specified period. Interviews with nursing staff and facility leadership revealed that the responsibility for entering and ensuring monitoring for anticoagulant side effects was not fulfilled. The nurse assigned to the resident did not see any monitoring listed in the electronic record, and the ADON acknowledged that the monitoring was overlooked and not added to the computer system. The facility did not have a policy on anticoagulant monitoring or medication administration, and the lack of monitoring was attributed to an oversight by the admitting nurse and a lack of backup checks by other staff.