Failure to Accurately Transcribe and Implement Eliquis Dose Change
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration for one resident when staff did not follow the prescriber's clarified order for Eliquis dosing. The resident was admitted with diagnoses including post-hip arthroplasty, osteoarthritis, atrial fibrillation, and panic disorder, and had an MDS BIMS score of 15/15 indicating intact cognition. Hospital discharge paperwork ordered Eliquis 5 mg twice daily for DVT prevention, with instructions to give 2.5 mg twice daily for the first seven days post-operatively. A subsequent physician communication on 12/23/25 clarified that the resident should receive Eliquis 2.5 mg twice daily through 12/25/25 and 5 mg twice daily starting on 12/26/25, and a nursing note documented that the order was changed accordingly and the family was updated. Despite this clarification and documentation, the December MAR showed that the resident continued to receive Eliquis 2.5 mg twice daily from 12/19/25 through 12/26/25, totaling eight days at the lower dose, and the 5 mg twice daily dose was not started until 12/27/25. This resulted in the resident receiving two incorrect doses of Eliquis on 12/26/25, contrary to the prescriber's order and the facility's Administering Medications policy, which requires medications to be administered in accordance with prescribers' orders. During interview, the NHA confirmed that the Eliquis dose should have been increased on 12/26/25 and acknowledged that a transcription error may have occurred when the order was entered.
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