F0760

D

Missed Anticoagulant Doses for New Admission

Tyler, Texas Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the administration of apixaban (Eliquis), an anticoagulant prescribed to treat and prevent blood clots. The resident, an adult male with multiple traumatic fractures and a documented history of pulmonary embolism, was admitted from an acute hospital stay with orders to receive apixaban 5 mg by mouth twice daily. The hospital discharge summary showed the last dose was given on the morning of 1/1/26, and the physician order at the facility, with a start date of 1/2/26, also directed apixaban 5 mg twice daily. The MDS indicated the resident was cognitively intact, able to make himself understood, and had received anticoagulant therapy during the look-back period, but his care plan dated 1/5/26 did not address anticoagulant administration.

Record review of the January 2026 MAR showed the resident did not receive his scheduled evening dose of apixaban on 1/1/26 or his morning dose on 1/2/26. Nursing progress notes for those dates contained no documentation that apixaban was administered for those missed doses. During interview, the resident’s family member reported that the resident had not been given his anticoagulant medication on those two days while at the facility, although the family member stated the resident did not develop a blood clot while there. LVN A, who cared for the resident on 1/1/26 (6:00 a.m. to 6:00 p.m.) and 1/2/26 (6:00 a.m. to 6:00 p.m.), stated she did not administer apixaban on 1/1/26 because the resident arrived late in the shift and could not recall if she administered it on 1/2/26, adding that any administration should have been documented on the MAR. Facility staffing records showed the resident was assigned to LVN C on the 6:00 p.m. to 6:00 a.m. shift spanning 1/1/26 to 1/2/26, but LVN C could not be reached for interview.

The ADON and DON explained that for new admissions, significant medications such as apixaban are available through the pharmacy-supplied E-kit once orders are entered and a code is provided by the contracted pharmacy, and that Eliquis was stocked in the E-kit. Review of the E-kit inventory confirmed that Eliquis 2.5 mg doses were in stock at the facility. The pharmacy consultant reported that no Eliquis was pulled from the E-kit on 1/1/26 or 1/2/26. The facility’s policies on administering medications and emergency medication ordering required that medications be administered safely, timely, as prescribed, and that emergency or STAT medications obtained from emergency drug kits be entered into the EHR and documented on the eMAR. Despite these policies and the availability of Eliquis in the E-kit, there was no evidence that the resident’s ordered apixaban doses for the evening of 1/1/26 and the morning of 1/2/26 were obtained or administered, resulting in the identified medication errors.