Failure to Document Monitoring for Anticoagulant Therapy
Penalty
Summary
Nursing staff failed to document monitoring for signs and symptoms of bleeding on the medication administration record (MAR) for a resident who was prescribed Apixaban, an anticoagulant. The resident had multiple diagnoses, including hypotension, hyperlipidemia, and atrial flutter, and was dependent on staff for all activities of daily living. The care plan required monitoring and documentation of bleeding every shift due to the use of Apixaban, but this was not completed or recorded on the MAR as required. During interviews, both the LVN and RN confirmed that monitoring for bleeding and bruising was not being documented, and the Director of Nursing acknowledged that this documentation should have been present on the MAR. Review of facility policy indicated that licensed nurses are required to monitor and document for signs and symptoms related to high-risk medications, including Apixaban, and to inform the attending physician of any findings. The lack of documentation indicated that the required monitoring was not performed.