Failure to Monitor for Bleeding in Resident Receiving Heparin
Penalty
Summary
The facility failed to ensure that a resident receiving heparin, an anticoagulant medication, was properly monitored for signs and symptoms of bleeding as required. The resident was readmitted and had physician's orders to receive heparin injections for DVT prophylaxis, with an additional order to monitor for bleeding every shift. The resident's care plan also included interventions to monitor for bruising and bleeding and to notify the physician if these were observed. A review of the medical record revealed there was no documented evidence that the resident was monitored for bleeding from the start of the heparin therapy until several days later. Interviews with an LVN and the DON confirmed that monitoring for bleeding should have begun when the medication was started, and both acknowledged the lack of documentation for this monitoring during the specified period.