Failure to Ensure Accurate Medication Documentation and Administration for Anticoagulation Therapy
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's medical record was clear and accurately documented in accordance with accepted professional standards and practices. The resident, who had recently suffered bilateral femur fractures and was admitted following surgery, was observed with hard braces on both legs and reported pain managed with Tylenol. The resident also stated she had been diagnosed with bilateral Deep Vein Thrombosis (DVT) and was taking Eliquis, an anticoagulant, for this condition. Review of her medical record confirmed the DVT diagnosis and documented a plan from the orthopedic surgeon to use Lovenox for DVT prophylaxis, with a switch to Eliquis planned once her hemoglobin stabilized. However, progress notes from the nurse practitioner indicated that Lovenox should be continued, and Eliquis should only be started when hemoglobin levels were between 8.5 and 9. Despite these documented plans, the Medication Administration Record showed that the resident was receiving Eliquis and not Lovenox. Nursing staff, upon review, acknowledged the discrepancy between the medication orders and what was being administered. The nurse practitioner confirmed in an interview that the resident should have been on Lovenox until her hemoglobin stabilized, which had not yet occurred according to recent lab results. This inconsistency in documentation and medication administration led to the deficiency cited in the report.