F0684

D

Failure to Resume Ordered Anticoagulant After Hospital Discharge

Flourtown, Pennsylvania Survey Completed on 10-06-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for an anticoagulant medication during admission/readmission medication reconciliation and subsequent care. Facility policy on medication reconciliation, revised July 2017, requires staff to gather all relevant documentation (including discharge summaries, admission orders, previous MARs, and medication history), compile a complete and accurate list of medications with dose, route, frequency, and indication, and review this list for discrepancies, documenting all findings and provider communications. Resident R1, cognitively intact with a BIMS score of 13, had multiple cardiovascular diagnoses including peripheral vascular disease, chronic heart failure, acute ischemic heart disease, coronary artery disease, cardiomyopathy, and endocarditis, as well as anxiety. Physician orders from July through September 2025 included Eliquis (apixaban) 5 mg to be administered twice daily.

Review of the MAR showed Eliquis was held for an upcoming surgery and last administered on July 14, 2025, with no further doses given until September 26, 2025. Hospital discharge orders dated 7/22/25, 8/4/25, and 9/26/25 each directed that Eliquis 5 mg be continued, including twice daily dosing. Despite these orders, the medication was not re-entered into the electronic health record or administered for approximately nine weeks. The DON confirmed that Eliquis had not been given during this period and believed it had been discontinued prior to surgery and never reordered. A licensed nurse acknowledged it was her responsibility to verify all medications post-hospitalization and stated that the Eliquis order was unintentionally missed, despite standard protocol to confirm medications with hospital staff at discharge and upon the resident’s return.