Failure to Monitor for Adverse Effects of Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral vascular accident, diabetes mellitus, hypertension, major depressive disorder, deep vein thrombosis, and pulmonary embolism was prescribed Apixaban, an anticoagulant, for deep vein thrombosis of the lower extremity. The resident's care plan identified a risk for bleeding and bruising due to anticoagulant therapy, and it directed nurses to assess for signs and symptoms of bleeding. However, review of the resident's Medication Administration Record (MAR) and Order Summary Report revealed there was no documented order or evidence that nurses were monitoring for adverse effects, such as bleeding, while the resident was on anticoagulant therapy. Interviews with nursing staff and the Director of Nursing confirmed that monitoring for adverse effects, particularly bleeding, is required for residents on anticoagulant medications. The facility's policy also stated that residents receiving medications with potential adverse consequences must be monitored to ensure prompt identification and reporting of such effects. Despite this, there was no documentation in the MAR indicating that monitoring for bleeding was being performed for this resident while on Apixaban.