Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
The facility failed to monitor for adverse effects of an anticoagulant medication for one resident who was prescribed Apixaban for acute embolism and thrombosis of the femoral vein. Review of the resident's physician orders, medication administration record, and treatment administration record revealed that there was no monitoring protocol in place to observe for side effects associated with anticoagulant therapy, such as bleeding or excessive bruising. The facility's policy required observation for adverse effects and physician notification if any occurred, but this was not implemented for the resident in question. Interviews with staff, including an LPN, the MDS Coordinator, and the DON, confirmed that there were no specific orders or monitoring tasks in place to assess for bleeding risks related to the anticoagulant medication. Staff emphasized the importance of such monitoring and acknowledged its absence, noting that monitoring should begin whenever an anticoagulant is prescribed. The resident involved was cognitively intact and had been admitted with a diagnosis of acute embolism and thrombosis.