Failure to Follow Discharge and Physician Orders for Anticoagulant Therapy
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and hospital discharge instructions regarding anticoagulant therapy, resulting in repeated significant medication errors for one resident. The facility’s policy on transcription of physician orders requires review and clarification of hospital discharge summaries with the physician and discontinuation of previous orders when medication orders change. The resident, who had a care plan identifying risk for bleeding complications related to anticoagulant use, had recently sustained a subdural hematoma and subarachnoid hemorrhage after a fall and was treated in the hospital. The hospital discharge summary documented that neurosurgery directed that aspirin and any antiplatelet/anticoagulant medications be held until a follow-up visit with repeat imaging, and Eliquis was not listed among the active discharge medications. Despite these instructions, the resident’s Medication Administration Records show that Eliquis 5 mg twice daily was administered on multiple dates after readmission. The February MAR documents Eliquis was given from early to mid-month and again from mid- to late-month, and the March MAR shows additional doses administered, with the medication intermittently placed on hold. A physician progress note later documented to continue holding Eliquis until neurosurgery re-evaluation, and a neurosurgery note indicated the brain bleed had resolved and recommended individualized discussion before resuming Eliquis. The attending physician stated that Eliquis should have been held upon readmission, and the DON acknowledged that the Eliquis order was initially missed when cross-referencing prior orders with the hospital discharge orders, and that the medication was resumed again due to a hold order being entered with a limited duration, leading to further doses being given before the error was identified.
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.