Failure to Administer Ordered Anticoagulant and Notify Physician When Medication Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of care and physician orders for anticoagulant therapy for one resident. The resident had diagnoses of atrial fibrillation and atrial flutter and a physician’s order, originally dated 6/27/25 and active in December 2025, for Xarelto 15 mg to be given once daily in the evening. The resident’s care plan, dated 7/7/25, documented that the resident was on anticoagulant therapy related to atrial fibrillation and directed staff to administer anticoagulant medications as ordered. Review of the December 2025 MAR showed that Xarelto was not administered on six consecutive days (12/11/25 through 12/16/25), with staff documenting that they were awaiting the medication on all six days. Staff interviews revealed multiple failures to obtain and administer the ordered medication and to follow required notification processes. One LPN reported that on 12/11/25 Xarelto was not available in the medication cart or emergency kit, and although this was reported to the charge nurse, the LPN did not notify the pharmacy, physician, DON, or administrator and was unsure of the pharmacy process when a medication was unavailable. The charge nurse (another LPN) confirmed that Xarelto was not available on 12/11/25, stated that he/she usually did not contact the pharmacy and believed CMTs were responsible for that task, and acknowledged that he/she did not notify the physician or on-call physician that the medication was not available or not administered. The charge nurse stated that a request to the pharmacy was sent on 12/12/25 and that the resident did not receive Xarelto from 12/11/25 through 12/16/25. Review of the communication platform between the facility and the pharmacy showed that on 12/12/25 the pharmacy requested an updated order for Xarelto following the resident’s readmission, and on 12/15/25 the pharmacy again indicated it could not refill the medication because the order was over a year old and requested an updated order. There was no documentation in the resident’s progress notes that an updated order was sent to the pharmacy between 12/12/25 and 12/15/25. The DON stated she was not informed that the resident had missed Xarelto doses from 12/11/25 through 12/16/25, was not aware of the process for reinstating an order with the pharmacy until this case, and confirmed that staff did not notify the physician or on-call physician when the resident did not receive Xarelto during that period. The resident reported going without his/her blood thinner for five to six days in December, and the physician stated the resident was to receive an anticoagulant daily for atrial flutter and stroke prevention and that staff did not notify him/her that the resident went six days without the anticoagulant.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.