Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring and administering of medications for a resident, identified as Resident R34. The facility's policy on 'Unavailable Medication' requires nursing staff to contact the pharmacy, attempt to obtain the medication from the facility's automated dispensing system, notify the physician, report the expected delivery date, and obtain new orders if a medication is unavailable. However, for Resident R34, who was on anticoagulant therapy with Warfarin for blood clot prevention, these procedures were not followed. The resident's medication administration record showed that Warfarin doses were not administered on multiple occasions, with notes indicating the medication was 'awaiting pharmacy,' but there was no documented evidence that the pharmacy was contacted or that the physician was informed of the missed doses. Resident R34, who was cognitively intact and had diagnoses of polycythemia vera and atrial fibrillation, was at risk due to the missed doses of Warfarin, an anticoagulant medication. The facility's failure to ensure the availability and administration of this critical medication was confirmed through staff interviews, where a registered nurse attributed the missed medications to the pharmacy's untimely delivery. This deficiency highlights a breakdown in the facility's pharmaceutical services, as the necessary steps to address the unavailability of medication were not documented or executed, potentially compromising the resident's care.
Plan Of Correction
1) Resident 34 medication is now available from pharmacy. 2) Current residents ordered anticoagulants will be audited to ensure availability of medication from pharmacy. Variances to be addressed. 3) Director of Nursing / Designee will educate licensed nursing staff on facility medication availability policy and procedures. 4) Director of nursing / Designees will conduct audits weekly x 3, then monthly x 2 or until compliance is met to ensure compliance with med availability policy. Variances will be addressed and reported to The QAA Committee.