F0757

D

Failure to Monitor Anticoagulant and Antihypertensive Medications as Ordered

Arlington, Virginia Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure residents’ drug regimens were free from unnecessary drugs by not implementing required monitoring for medications with significant risk profiles. For one resident receiving Enoxaparin Sodium 40 mg daily for DVT prophylaxis, a physician’s order dated 2/12/26 directed staff to monitor for specific anticoagulant side effects, including discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nosebleeds, with documentation of ‘Y’ or ‘N’ on the MAR to reflect monitoring and findings. Review of the clinical record, including the February 2026 MAR, treatment administration record, and nurses’ notes, showed that this monitoring order was not implemented, despite daily administration of Enoxaparin from 2/12/26 through 2/20/26 and staff acknowledgment that such monitoring should be documented on the MAR.

Another resident had a physician’s order for Metoprolol Tartrate 12.5 mg once daily for hypertension, with parameters to hold the dose if the systolic blood pressure was less than 100. The February 2026 MAR reflected the order but did not provide a place to record the blood pressure reading prior to administration. Review of the vital signs section and skilled nurses’ notes revealed no documented blood pressures on several days when the medication was ordered, and there was no evidence that blood pressure was taken before administration on those dates. An LPN stated that when a medication has parameters, the nurse should take the blood pressure and, if the medication is held, notify the physician, but the documentation reviewed did not show that this process occurred on the identified days.

A third resident with diagnoses including hypertension and atrial fibrillation with a pacemaker was receiving anticoagulant therapy, as reflected on a recent MDS and a comprehensive care plan that focused on anticoagulant use and included an intervention that the resident would be free of discomfort or adverse reactions related to anticoagulant therapy. A physician’s order dated 12/28/25 directed Apixaban 2.5 mg orally every morning and at bedtime for coagulation management. Review of the MARs for December 2025, January 2026, and February 2026 showed no documentation of anticoagulation monitoring since admission, despite the ongoing Apixaban therapy and the care plan focus on monitoring for adverse reactions. An LPN described the facility’s process for monitoring anticoagulant side effects, including checking for blood in stool or urine, bruising, and ecchymosis and notifying the provider, but the resident’s records did not contain evidence that such monitoring was documented.