Failure to Monitor and Document Anticoagulant Therapy
Penalty
Summary
The facility failed to follow professional standards of nursing practice for monitoring anticoagulant therapy for one resident. The resident, who had multiple diagnoses including cerebral palsy, atrial fibrillation, COPD, diabetes, schizophrenia, and hypertension, was prescribed Xarelto (Rivaroxaban) for atrial fibrillation. Physician orders and the resident's care plan required staff to monitor, document, and report signs and symptoms of anticoagulant complications. However, a review of the Treatment Administration Record (TAR) from July through September showed that staff did not document monitoring for anticoagulant signs and symptoms on several PM shifts. During an interview, the Director of Nursing confirmed that the TAR should have been marked as completed on those dates.