F0755

D

Medication Management and Communication Failures with Eliquis Dose Reduction During Paxlovid Therapy

Greenfield, Wisconsin Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly manage and communicate physician-ordered changes to an anticoagulant (Eliquis) when an antiviral (Paxlovid) was initiated for a resident with a history of deep vein thrombosis (DVT). The resident was admitted on 04/07/22 and had an existing order for Eliquis 5 mg every 12 hours, with the last dose to be administered on 02/11/26. On 02/02/26, the Medical Director ordered Paxlovid 150 mg-100 mg twice daily for four days. The pharmacy’s receipt of the Paxlovid order generated a level one interaction flag because the resident was also on Eliquis, and the pharmacist contacted the Medical Director, who then ordered a reduction of Eliquis to 2.5 mg twice daily for eight days.

Despite this new order, the facility’s medication administration records and staff interviews show that the Eliquis dose reduction and hold parameters were not consistently implemented or communicated. The Medication Record for 02/2026 shows that Eliquis 5 mg doses were variably held and administered: the AM dose was held on multiple days between 02/04/26 and 02/08/26, and the PM dose was held on several days but still administered on 02/06/26 and 02/07/26. A separate Physician Orders document dated 02/03/26 reflects the Eliquis 2.5 mg twice daily order, with administration documented from 02/03/26 to 02/08/26. As a result, the resident received both Eliquis 5 mg and 2.5 mg during overlapping periods, leading to total daily doses of 7.5 mg on some days instead of the intended reduced regimen.

Staff interviews further describe communication and process failures contributing to the error. One LPN stated she was unaware of the Eliquis dose reduction, returned the 2.5 mg tablets to the pharmacy upon receipt, and did not place a hold on the 5 mg evening dose, even after later writing the 2.5 mg order for eight days. The nurse supervisor reported that the Medical Director reduced the Eliquis dose due to the resident being placed on Paxlovid and that there was a communication failure regarding this change. The Lead Consultant Pharmacist stated that after the interaction alert and dose reduction, her expectation was that the pharmacist would contact the facility to alert nursing staff of the new order. The DON reported that a new LPN administered Eliquis 7.5 mg on two days, and the facility’s Medication Incident Report documented that three PM doses of Eliquis 5 mg were given when they should have been held, resulting in the resident receiving Eliquis 7.5 mg for three days while on Paxlovid, with the potential for increased risk of severe bleeding noted in the deficiency.