Failure to Document Medication Side Effect Monitoring
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not consistently documenting the required monitoring for side effects of anticoagulant and anticonvulsant medications. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, atrial fibrillation, atherosclerotic heart disease, hypertensive heart disease with heart failure, seizures, and diabetes mellitus, was prescribed Eliquis (an anticoagulant) and Levetiracetam (an anticonvulsant). Physician orders required monitoring for side effects of these medications every shift, and the resident’s care plan included interventions to monitor and document side effects and effectiveness of the medications. Record reviews revealed that the facility failed to document the required monitoring for side effects on multiple occasions in both November and December. Specifically, there was no documented evidence of monitoring for 13 instances in November and 5 instances in December, despite the resident receiving both medications during these periods. Interviews with nursing staff confirmed that the monitoring was not documented as ordered while the resident was on these medications.