Failure to Document Anticoagulant Side Effect Monitoring
Penalty
Summary
The facility failed to document side effect monitoring for a resident prescribed an anticoagulant medication. The resident, who had diagnoses including edema, muscle weakness, and hyperlipidemia, was observed with bruising on both hands while ambulating in a wheelchair. The resident's care plan and facility policy required monitoring for adverse consequences of anticoagulant use, such as signs and symptoms of bleeding, and documentation of these findings. However, the Treatment Administration Record (TAR) from February through May did not include documentation of the observed bruising or any related side effect monitoring for anticoagulant use, nor was the bruising noted in the skin inspections. Interviews with the resident, an LPN, and the DON confirmed that the bruising was not documented in the TAR or skin inspections, despite the resident's report of easy bruising due to anticoagulant therapy and the staff's awareness of the bruising. The facility's policy specifically identified the need for staff to monitor and document adverse effects of high-risk medications like anticoagulants, but this was not followed in the case of this resident.