Failure to Monitor and Document Adverse Reactions to Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident receiving Apixaban, an anticoagulant medication, was adequately monitored for signs and symptoms of bleeding as required by physician orders and facility policy. The resident, who had diagnoses including obstructive pulmonary embolism and atrial fibrillation, was cognitively intact but required moderate assistance with daily tasks. The care plan and physician orders specified that the resident should be monitored every shift for adverse reactions such as bruising, discolored urine, black tarry stools, and other symptoms associated with anticoagulant therapy, with documentation required on the Medication Administration Record (MAR). Despite these requirements, documentation on the MAR from the relevant period consistently indicated 'No' for observations of bruising, and there was no record of bruising being observed or reported by nursing staff during this time. The resident later reported to staff that she had bruising on her arms, which she believed was related to her medication. The nurse only became aware of the bruising after being informed by the resident's daughter, not through direct observation or documentation. The nurse practitioner was notified of the bruising but did not document the assessment in the medical record and did not notify the medical doctor, as she did not consider the situation urgent. Interviews with facility staff, including the medical director and pharmacy consultant, confirmed that monitoring for adverse reactions to anticoagulant therapy is required and that physician orders must be followed. Facility policy also mandates immediate reporting and documentation of suspected adverse drug reactions, as well as notification of the pharmacist. The lack of proper monitoring, documentation, and timely notification regarding the resident's bruising constituted a failure to meet pharmaceutical service requirements for residents receiving high-risk medications.