Failure to Document Monitoring for Anticoagulant and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and documentation for residents receiving anticoagulant and insulin therapy, as required by its medication administration policy. For one resident with diabetes and a history of left above-knee amputation, admission orders included aspirin 81 mg daily, Xarelto 20 mg daily with breakfast, and insulin lispro 5 units subcutaneously with meals. Review of this resident’s medication administration records for January, February, and March 2026 showed no documentation that nursing staff monitored for signs or symptoms of bleeding related to the blood thinners or for signs or symptoms of hypoglycemia or hyperglycemia related to the insulin. Another resident with diabetes had an order for Lantus 25 units subcutaneously twice daily at 9:00 a.m. and 9:00 p.m., but the clinical record lacked documentation that nursing staff monitored for signs or symptoms of hyperglycemia or hypoglycemia. Two additional residents receiving anticoagulant therapy also lacked documented monitoring for bleeding. One resident with chronic embolism and thrombosis of the right upper extremity had an order for apixaban 5 mg twice daily at 8:00 a.m. and 8:00 p.m., yet the clinical record showed no documentation of bleeding assessments from March 12 through March 16, 2026. Another resident with hypotension and cardiovascular disease had an order for apixaban 5 mg twice daily at 8:00 a.m. and 8:00 p.m. for cardiovascular health, but the record similarly lacked documentation of monitoring for signs of bleeding. During an interview, an LPN confirmed that residents on blood thinners should be monitored for signs of bleeding and residents on insulin should be monitored for hyperglycemia and hypoglycemia, and that such monitoring should be documented on the medication administration record. The facility’s Medication Administration Policy Guideline stated that medications are to be administered as prescribed and in accordance with good nursing principles and practices.
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