Failure to Monitor for Adverse Reactions to Anticoagulant Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure adequate monitoring for adverse reactions to high-risk anticoagulant medications for three residents who were prescribed Eliquis. Each resident had physician orders for Eliquis due to conditions such as chronic embolism, thrombosis, cerebral infarction, and congestive heart failure. Despite these orders and the known risks associated with anticoagulant therapy, the facility did not implement or document medication monitoring for potential adverse side effects in the residents' medical records. For each resident, the care plans included interventions to monitor for adverse reactions and signs or symptoms of bleeding, such as tarry stools, blood in urine, bruising, and petechiae. However, upon review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) for the relevant periods, surveyors were unable to locate any evidence of medication monitoring related to the use of Eliquis. This lack of documentation was consistent across all three residents reviewed. Interviews with the Director of Nursing confirmed that residents receiving anticoagulant therapy should be monitored for side effects every shift by nursing staff. When informed of the absence of medication monitoring documentation, facility leadership did not provide any additional information or evidence to demonstrate that such monitoring had occurred. The deficiency centers on the facility's failure to follow through with required monitoring practices for residents on high-risk medications, as outlined in their care plans and standard protocols.