Failure to Reconcile and Administer Correct Eliquis Dosage
Penalty
Summary
The facility failed to ensure proper medication reconciliation for a resident who was admitted with multiple complex medical conditions, including infected amputated stump, renal dialysis, diabetes mellitus type 2, peripheral vascular disease, and bilateral below-knee amputations. Upon return from a general acute care hospital, the resident's discharge medication list specified Eliquis 2.5 mg to be taken orally twice daily. However, the facility's order summary and medication administration record indicated that Eliquis 5 mg was administered twice daily for four doses, which was double the intended strength. Interviews and record reviews revealed that the medication list from the hospital was reviewed and sent to the physician for reconciliation, but the discrepancy in Eliquis dosage was not identified before administration. The DON confirmed that the resident received the higher dose before a telephone order was obtained to confirm the medication. The facility's policy required careful comparison of pre- and post-discharge medications, including dose, route, and frequency, to prevent unintended changes, but this process was not effectively followed, resulting in the administration of an incorrect medication dose.