Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that Resident 21 was free from significant medication errors. A review of the clinical records and staff interviews revealed that Resident 21, who was cognitively intact and required assistance for personal hygiene due to a right femur fracture, did not receive the prescribed medication, Coumadin, from October 2 through October 15, 2024. The medication orders specified that 2.5 mg of Coumadin should be administered every Monday, Wednesday, and Friday, and 2 mg every Tuesday, Thursday, Saturday, and Sunday. However, the Medication Administration Record (MAR) for October 2024 showed no documented evidence of Coumadin administration during this period. The Director of Nursing confirmed that the medication should have been administered as ordered.
Plan Of Correction
Resident 29 Coumadin orders were reviewed; resident is receiving Coumadin per physician orders. Residents who receive Coumadin have the potential to be affected. Baseline audit was completed on residents receiving Coumadin. The Director of Nursing completed education to licensed nurses on the process for obtaining Coumadin orders, including transcription of orders. Monitoring will be captured through auditing Coumadin orders. Audits will be conducted on up to 2 clinical records weekly for 4 weeks, then up to 2 clinical records twice monthly for 2 months. Audits will be conducted by the Director of Nursing. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at the QAPI Committee meeting.