Failure to Monitor and Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that two residents receiving apixaban, an anticoagulant, were monitored for side effects and had appropriate care plans in place regarding the use of this medication. For both residents, physician orders were present for apixaban administration, but their clinical records did not show evidence of monitoring for adverse effects or documentation of care planning related to the medication. The interim director of nursing confirmed during interviews that neither resident was monitored for side effects nor had a care plan addressing the use of apixaban. The facility's own anticoagulation clinical protocol required assessment for signs or symptoms of adverse drug reactions, but this was not followed for the two residents in question. The lack of monitoring and care planning was identified through record review and staff interviews, indicating a failure to comply with both physician orders and facility policy regarding the safe administration and oversight of anticoagulant therapy.