Failure to Monitor for Adverse Effects of Anticoagulant Medication
Penalty
Summary
The facility failed to ensure adequate monitoring for a resident receiving an anticoagulant medication, apixaban, which was prescribed for pulmonary embolism and deep vein thrombosis. According to the facility's High-Alert Medication Monitoring Policy, residents on high-risk medications are to be routinely assessed for adverse side effects, with observations documented in the clinical record. However, review of the physician's order summary and the Medication Administration Records (MARs) for April and May 2025 showed that there was no order for monitoring adverse side effects related to anticoagulant use, nor was there documentation of such monitoring for the resident in question. Interviews with nursing staff, including a Registered Nurse, the Minimum Data Set Coordinator, and the Director of Nursing, confirmed that the resident had not been adequately monitored for adverse side effects from anticoagulant use. Staff acknowledged that there was no physician's order for monitoring, and the required monitoring was not performed or documented. This lack of monitoring was contrary to facility policy and was confirmed through both record review and staff interviews.