Concurrent Administration of Eliquis and Xarelto Due to Medication Order Errors
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when both Eliquis and Xarelto were ordered and administered contrary to the hospital discharge instructions. The resident was admitted with diagnoses including STEMI, congestive heart failure, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure. The hospital discharge summary documented that Eliquis had been changed to Xarelto, with a loading dose of Xarelto 15 mg twice daily starting on 12/7/2025 and a planned transition to Xarelto 20 mg daily on 12/29/2025. Upon admission, Xarelto was ordered as directed; however, multiple Eliquis orders were subsequently entered and then discontinued on 12/10/2025, 12/11/2025, and 12/15/2025. The DON stated that the Eliquis order was stopped and restarted to change the indication from DVT to atrial fibrillation. The LPN supervisor reported that the Eliquis orders were created by the pharmacy and verified with the provider, but he could not explain why they were created. The Unit Manager RN acknowledged that the resident was supposed to be on Xarelto per the hospital discharge orders and identified the Eliquis orders as errors on multiple dates, contacting the provider to verify the correct Xarelto order and discontinuing Eliquis each time. Despite these discontinuations, Eliquis continued to appear on the MAR. Review of the December 2025 MAR showed that on 12/16/2025 at the 9:00 AM medication pass, the resident received Eliquis 5 mg along with Xarelto 15 mg, resulting in the administration of both anticoagulants. LPN #18 confirmed administering both medications as documented. The DON later confirmed, upon review of the MAR, that the resident received both Xarelto and Eliquis during that medication administration, and that the resident should have remained on Xarelto per the hospital discharge orders. The administration of both anticoagulant medications increased the resident's risk for bleeding.
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