Failure to Monitor for Anticoagulant Complications
Penalty
Summary
The facility failed to ensure that the drug regimens of three residents prescribed anticoagulant medications were free from unnecessary drugs by not monitoring for signs and symptoms of anticoagulant complications as required. For each of these residents, the care plans and physician orders included the use of anticoagulants such as Eliquis (Apixaban) and Rivaroxaban for conditions like pulmonary embolism, atrial fibrillation, and blood clots. However, there was no evidence in the medical records, medication administration records, progress notes, or assessments that staff were monitoring for adverse effects such as bleeding, bruising, changes in mental status, or abnormal vital signs. Interviews with nursing staff and review of facility policy revealed that while staff were aware of the need to monitor for complications associated with anticoagulant therapy, this monitoring was not documented or ordered in the residents' records. The facility's policy on high-risk medications specifically requires staff to monitor and document for adverse consequences of anticoagulant use, including bleeding and thromboembolism, and to alert staff through the care plan. Despite this, the surveyor was unable to locate any documentation of such monitoring for the three residents in question. Additionally, one resident's care plan did not include any interventions related to anticoagulant monitoring, and there was no physician order to monitor for complications. Nursing staff confirmed that monitoring was based on nursing judgment and not consistently documented. The facility did not provide any explanation for the lack of daily monitoring for signs and symptoms of anticoagulant complications in these residents.