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F0757
D

Failure to Monitor Anticoagulant Therapy for Two Residents

Jefferson, Wisconsin Survey Completed on 06-23-2025

Penalty

10 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents' drug regimens were free from unnecessary medications by not adequately monitoring the use of anticoagulant medications, specifically Eliquis. One resident with a history of atrial fibrillation and hypertension, who was rarely to never understood, was prescribed Eliquis 5 mg twice daily. Review of the resident's medical records, including physician orders, MAR, and TAR, revealed no documented monitoring for potential adverse effects of the anticoagulant, such as bleeding, bruising, or fatigue, during the assessment period. Another resident, cognitively intact and diagnosed with pulmonary embolism, paraplegia, Parkinson's disease, Alzheimer's disease, dementia, mood disturbance, and anxiety, was also prescribed Eliquis 5 mg twice daily. Similarly, there was no documentation in the MAR or TAR of monitoring for signs and symptoms of adverse effects from the medication. Staff interviews confirmed that monitoring for side effects should occur and be documented, but the facility lacked a policy for monitoring anticoagulants like Eliquis or Xarelto, having only a policy for Warfarin. No further information or documentation was provided by the facility regarding monitoring practices.

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