Failure to Administer and Monitor Anticoagulant Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including atrial fibrillation, diabetes mellitus, major depressive disorder, and anemia, was not properly administered and monitored for an anticoagulant medication, Eliquis. The resident's care plan and physician orders required administration of Eliquis twice daily and monitoring for specific signs and symptoms of bleeding or adverse effects every shift. Documentation in the medication administration record (MAR) showed that on one day, the medication was not recorded as given, and required monitoring was not documented for the day shift. Interviews with nursing staff and the Director of Nursing confirmed the importance of adhering to physician orders for both medication administration and monitoring, especially for residents on blood thinners due to the high risk of bleeding. Staff acknowledged that if documentation was left blank, it indicated that the medication was not administered and monitoring was not performed as required. The facility's policy also required licensed nurses to document and implement physician orders and maintain accurate records. The failure to administer the prescribed dose of Eliquis and to document required monitoring for side effects on the specified date constituted a lapse in following physician orders and facility policy. This inaction had the potential to delay necessary care and services for the resident, as noted in the findings.