Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure appropriate side effect monitoring for a resident receiving anticoagulant therapy. The resident, who had severe cognitive impairment and a history of stroke, deep venous thrombosis (DVT), depression, anxiety, dementia, and Alzheimer's disease, was prescribed Eliquis for DVT. The medication order did not include any special instructions or label comments regarding side effect monitoring. The resident's care plan identified risks related to other medications but did not address anticoagulant use, increased risk for bleeding, or the need for monitoring side effects associated with anticoagulant therapy. Interviews with facility staff, including an LPN, DON, MDS nurse, and consultant pharmacist, confirmed that instructions for monitoring side effects should be present in the electronic medication administration record (EMAR) and the care plan, but were absent in both for this resident. The facility's own policy required staff to assess for adverse drug reactions and monitor for complications such as excessive bruising or bleeding. Despite this, there was no documentation or instruction in the care plan or EMAR to guide staff in monitoring for anticoagulant side effects for this resident.