Failure to Monitor for Anticoagulant Side Effects
Penalty
Summary
The facility failed to monitor residents for side effects of anticoagulant medication use for two of five medication reviews. Specifically, there was no policy in place for anticoagulant monitoring, as confirmed by a facility letterhead signed by the Administrator. For one resident with a diagnosis of venous thrombosis and embolism, staff interviews revealed that although nurses were aware of the risks associated with anticoagulant use, there was no area in the electronic documentation system to prompt or record monitoring for bleeding or bruising. The RN/MDS and DON both confirmed that monitoring for side effects was not documented, and the DON acknowledged that this monitoring was necessary to ensure prompt evaluation and treatment of complications. For another resident with diagnoses including peripheral vascular disease and atrial fibrillation, staff interviews and record reviews showed that while nurses were expected to monitor for side effects such as bleeding or bruising, there was no documentation or monitoring tool in place to ensure this was done. The MAR confirmed that the resident received anticoagulant medication, but there was no order or documentation for monitoring side effects. Staff confirmed that the lack of monitoring placed the resident at risk, and there was no system in place to prompt or verify that monitoring occurred.