Failure to Monitor Residents on Apixaban for Bleeding
Penalty
Summary
The facility failed to ensure that two residents receiving apixaban, an anticoagulant medication, were properly monitored for signs and symptoms of bleeding as required by both FDA guidelines and the facility’s own policies and procedures. For one resident, who had a history of stroke and had been on blood thinners since 2016, there was no documented evidence in the medical record that monitoring for bleeding was performed. Interviews with nursing staff confirmed that such monitoring should occur, and the DON acknowledged the lack of documentation and monitoring for this resident. For the second resident, who was prescribed apixaban for atrial fibrillation, the medical record also lacked documentation of monitoring for bleeding. Additionally, the resident’s care plan did not address the use of apixaban, despite the resident being cognitively intact and aware of their medication regimen. Nursing staff and the DON confirmed that monitoring for bleeding should have been performed and documented every shift, but this was not done. Both residents were observed and interviewed, and both were aware of their anticoagulant therapy. However, the facility did not follow its own protocol, which requires staff to monitor for complications such as excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, and to notify the physician if such symptoms occur. The lack of monitoring and documentation was verified by staff and acknowledged by facility leadership during interviews.