Failure to Monitor and Document Anticoagulant Side Effects
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document monitoring for side effects of an anticoagulant medication for one resident. The resident was admitted with a history of venous thrombosis and embolism and had physician orders for rivaroxaban, initially 20 mg for DVT prevention and later changed to 10 mg once daily for anticoagulation. A pharmacist’s recommendation dated 09/05/25 directed staff to monitor the resident for bleeding or thromboembolism as potential side effects of the anticoagulant therapy. Record review of the resident’s entire medical record showed no documentation that staff monitored for side effects of the anticoagulant medication. During an interview, an LPN stated that the resident had an order for rivaroxaban, that nurses were supposed to monitor residents for anticoagulant side effects, and that such monitoring was expected to be documented in the MAR, but confirmed there was no such documentation for this resident. In a separate interview, the Regional Clinical Nurse confirmed that staff were expected to monitor for anticoagulant side effects, acknowledged the pharmacist’s recommendation to monitor for bleeding and thromboembolism, and confirmed that the resident’s record lacked documentation of this monitoring.
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