Failure to Monitor Anticoagulant Medication for Side Effects and Efficacy
Penalty
Summary
The facility failed to monitor the side effects and efficacy of an anticoagulant medication for a resident with a history of venous insufficiency and thrombocytopenia. The resident was admitted and prescribed apixaban, an anticoagulant, with orders to administer the medication for blood clot prevention. However, there was no order in place for staff to monitor the resident for side effects or efficacy of the anticoagulant until nearly a month after the medication was started. Review of the medication administration record (MAR) confirmed that while the medication was administered as ordered, there was no documentation of monitoring for side effects or effectiveness during this period. Interviews with the Director of Nursing Services (DNS), the South Unit Manager, and a Licensed Practical Nurse confirmed that monitoring for anticoagulant use should have been documented but was not done prior to the addition of the monitoring order. The DNS and other staff acknowledged the absence of both an order and documentation for monitoring the resident for adverse reactions or effectiveness of the anticoagulant medication until the oversight was identified and corrected.