Failure to Follow Physician Orders Leads to Resident Harm
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as confirmed by the Director of Nursing. Additionally, the facility did not follow physician orders for a lab test for one resident, leading to a significant deficiency. The resident in question, who was admitted with diagnoses including anemia, high blood pressure, and atrial fibrillation, was on a regimen of Coumadin, an anticoagulant medication. The physician had ordered an INR test to be conducted on a specific date to monitor the resident's blood clotting levels, but this test was not transcribed into the electronic health record and was therefore missed. As a result of the missed INR test, the resident experienced symptoms consistent with excessive anticoagulation, including bruising and nausea, and was eventually found to have an extremely high INR level. This led to the resident being sent to the emergency room with a dangerously high INR and subsequently readmitted to the facility after suffering a hemorrhagic stroke. The Director of Nursing confirmed the failure to follow physician orders, which was identified as the root cause of the resident's high INR and subsequent medical complications.
Plan Of Correction
1 - The facility is unable to retroactively correct the INR testing order for 11/24/2024. 2 - The facility reviewed all residents with INR testing orders. No issues were found. 3 - The Director of Nursing/designee will educate RN, LPN, physicians, and CRNP on proper entry of an INR testing order. 4 - The Director of Nursing/designee will audit new orders for INR testing for new orders for meds requiring testing, 5 days a week for 3 weeks, weekly for 3 weeks, then monthly until substantial compliance is achieved. 5 - Results will be reviewed at the Quarterly QA Meeting.