F0757

D

Failure to Discontinue Naproxen Ordered as Short Course in Resident on Eliquis

Tonasket, Washington Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when an anti-inflammatory medication, Naproxen, ordered for a limited duration, was entered and administered without an end date while the resident was also receiving the anticoagulant Eliquis. The resident had been admitted with atrial fibrillation and was taking Eliquis daily to reduce the risk of stroke or heart attack. On 12/02/2025, the physician documented that the resident had knee and shoulder pain and could start Naproxen 250 mg twice daily for two weeks, as a short course if renal and gastrointestinal status allowed. The resident care manager (Staff B) reviewed this note and entered the Naproxen order into the MAR on the same date but omitted the two-week stop date, resulting in an open-ended order.

The MAR showed that Eliquis was ordered once daily to continue until discharge, and Naproxen, entered on 12/02/2025 without an end date, was administered twice daily through the resident’s discharge on 02/25/2026. On 02/23/2026, staff identified significant dark blue/purple bruising on the resident’s inner thighs, buttocks, and perineal region, which was documented in a skin check and subsequent skin assessment with measurements of multiple bruised areas. During interviews, Staff B confirmed they had entered the Naproxen order without an end date despite the physician’s two-week limitation and could not recall why the end date was omitted. The DON (Staff A) confirmed the resident had been on Eliquis since admission and that Naproxen, intended as a two-week course, continued until discharge, and stated that the interaction between Eliquis and Naproxen could have caused the bruising identified on 02/23/2026.