Failure to Monitor for Adverse Reactions to Anticoagulant Medication
Penalty
Summary
The facility failed to ensure appropriate monitoring for adverse reactions to a high-risk medication for one resident receiving Eliquis, an anticoagulant prescribed for deep vein thrombosis prophylaxis. The resident had a history of pulmonary embolism and long-term anticoagulant use. Facility policy required monitoring for possible complications in individuals on anticoagulants, and the resident's care plan specifically directed staff to monitor daily for signs of active bleeding, such as hematuria, petechiae, bruising, bloody stools, or nosebleeds. Upon review of the resident's medical record, including progress notes, medication administration records, and treatment administration records, the surveyor was unable to find evidence that monitoring for complications from Eliquis was being performed. When questioned, nursing staff and management were unable to provide documentation or a standard practice supporting their claim of charting by exception for this monitoring. The lack of documented monitoring was confirmed by both the RN and the DON during the survey.