Failure to Monitor Anticoagulant Therapy
Penalty
Summary
Facility staff failed to provide evidence of monitoring anticoagulant medication use for one resident from 2/1/25 to 2/11/25. The resident, who had a history of pulmonary embolism and was on anticoagulant therapy with Apixaban as ordered by the physician, was readmitted to the facility and assessed as taking anticoagulant medication on the most recent MDS. The physician's orders and the resident's care plan both indicated the need for monitoring for signs and symptoms of anticoagulant complications, including bleeding, bruising, and changes in vital signs. Despite these orders and care plan interventions, the electronic medication administration record (eMAR) showed that while Apixaban was administered as prescribed, documentation of anticoagulant monitoring did not begin until the night shift on 2/12/25. There was no evidence of monitoring for adverse effects or complications related to anticoagulant use from 2/1/25 to 2/11/25. Staff interviews confirmed that monitoring should occur every shift and be documented in the eMAR, but this was not done during the specified period. Facility policies also required clinical and laboratory monitoring for residents on anticoagulants.