Failure to Resume Anticoagulant After Procedure Leads to Adverse Outcome
Penalty
Summary
A facility failed to resume an anticoagulant medication, Eliquis, for a resident with a history of deep vein thrombosis (DVT) and pulmonary embolus after it was temporarily discontinued for a scheduled medical procedure. The resident had been admitted with multiple diagnoses, including atrial fibrillation, type 2 diabetes, urinary retention, and a history of blood clots. Eliquis was discontinued on the instruction of the Nurse Practitioner (NP) prior to a suprapubic catheter placement, and no new order was entered to restart the medication after the procedure. The NP later stated that the electronic health record system required discontinuation rather than holding of medications, and she forgot to re-enter the order to restart Eliquis. The Medical Director and other staff also failed to identify that the medication had not been restarted, despite reviewing the resident's medication records multiple times and documenting that the resident was on Eliquis when he was not. Over the following months, the resident began to exhibit symptoms such as bilateral lower extremity edema, shortness of breath, and required supplemental oxygen. Despite these symptoms and multiple clinical assessments, the omission of Eliquis was not identified until a venous doppler was ordered due to leg swelling, which revealed a non-occluding DVT. Only then did the NP realize that the resident was not on anticoagulation and restarted Eliquis. Shortly after, the resident's condition worsened, leading to increased anxiety, hypoxia, and further clinical decline. The resident was eventually transferred to the hospital, where he was diagnosed with bilateral pulmonary emboli, including a complete occlusion in the right lower lobe, and required a heparin drip and thrombectomy. Throughout this period, documentation and interviews revealed that both the NP and Medical Director repeatedly referenced the resident as being on Eliquis in their notes, despite the medication not being administered. The failure to restart the anticoagulant after the procedure, combined with the lack of detection by multiple clinical staff and the limitations of the electronic health record system, directly led to the resident's adverse clinical outcomes, including hospitalization and invasive intervention for blood clots.
Removal Plan
- Audit of current residents on anticoagulant therapy by running current orders for anticoagulants and reviewing the orders for accuracy to determine whether any changes or adjustments with the anticoagulant were made, and verifying the appropriate administering or discontinuing of the medication as ordered.
- The DON ensures residents have their anticoagulant ordered and administered as required, and verifies that the medication is available in the medication cart.
- Audit of current residents on anticoagulant therapy and residents that had discontinued anticoagulant orders by the DON and the Assistant Director of Nursing (ADON).
- Audit by reviewing the Healthcare Practitioner's progress notes and provider's consultations to identify any other medication that have been discontinued specifically focused on anticoagulant medications and have not been restarted.
- Audit by the DON, ADON and the Pharmacy Consultant.
- If any further concerns are identified from the audit, the Healthcare Practitioner will be notified, and the resident will be evaluated.
- Ensure residents' medications will be administered, discontinued and restarted appropriately.
- Licensed Nurses are re-educated on the importance of ensuring a resident's medication, such as an anticoagulant, that is temporarily discontinued due to a procedure, treatment or hospitalization, has been restarted.
- Licensed Nurse must verify that the medication that the resident was taking prior to being discontinued has been reentered, verified and activated, if still deemed medically necessary.