Failure to Monitor and Manage High-Risk Anticoagulant/NSAID Drug Interaction
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for monitoring and preventing adverse consequences from drug interactions, specifically the concurrent use of an anticoagulant and an NSAID. The facility’s policy requires evaluation of new medication orders for incompatibilities with other medications, monitoring for adverse consequences when medications are added, and documentation that the prescriber has determined that the benefits of high‑risk combinations outweigh the risks. The policy also requires prompt physician notification, close monitoring, and documentation when significant adverse consequences occur, including those requiring hospitalization. The policy specifically identifies anticoagulants such as apixaban (Eliquis) and NSAIDs such as ibuprofen (Motrin) as a combination that can cause serious gastrointestinal bleeding and requires monitoring and prescriber documentation. Resident #12 was readmitted from the hospital with diagnoses including pulmonary embolism and had new orders for apixaban 5 mg and ibuprofen 400 mg. When these orders were entered into the electronic medical record system, a moderate drug–drug interaction alert was generated indicating that ibuprofen may enhance the anticoagulant effect of apixaban; the ADON signed off on this warning. There is no documentation that the prescriber provided the required justification that the benefits of this high‑risk combination outweighed the risks, nor is there evidence that staff implemented enhanced monitoring as outlined in the facility’s policy. Subsequently, nursing documentation showed that the resident became very weak, had a small amount of blood in her brief, and refused evening meals, fluids, and snacks. Over the next several hours, nursing staff documented that the resident continued to have hematuria and possible rectal bleeding in small to moderate amounts while receiving apixaban 10 mg BID and ibuprofen 400 mg QD, and the nurse asked the physician if the ibuprofen could be held. There is no evidence in the record that the physician responded to this question or that the ibuprofen was held at that time, despite ongoing bleeding. Later, a CNA reported, and a nurse confirmed, a gross amount of red blood in the resident’s brief consistent with a GI bleed, and the resident was sent to the emergency room, where she was found to have a GI bleed and a drop in hemoglobin. The facility census was 90, and this failure to follow policy and adequately address a known high‑risk drug interaction resulted in a hospitalization for this resident.
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