Failure to Follow Physician Orders for Warfarin Administration
Summary
A deficiency occurred when staff failed to follow physician orders for warfarin (Coumadin) administration for a resident with a history of atrial fibrillation, dementia, and a prosthetic heart valve. The resident had a prescribed warfarin dose of 5.5 mg daily, with a therapeutic INR goal of 2.5 to 3.5. Despite an elevated INR result of 6.7, a physician order was given to hold the warfarin dose and decrease the daily dose to 5.0 mg starting the following day. However, the Medication Administration Record (MAR) documented that the resident continued to receive 5.5 mg of warfarin on the day of the elevated INR and for the next three days. The resident's INR continued to rise, reaching 12.4 on a subsequent test. The resident was then admitted to the hospital with pneumonia, urinary tract infection, and a critically high INR of 13, requiring treatment with Vitamin K. Interviews with staff revealed confusion and lack of clarity regarding the process for holding medications, transcribing physician orders, and updating the MAR. Staff members were unsure about how to properly document and communicate hold orders, and there was inconsistency in the understanding of who was responsible for entering and confirming medication changes in the electronic health record system. The facility's policy required clear documentation and adherence to physician orders for anticoagulant use, including holding medications when lab values were outside the therapeutic range. Despite this, the resident received unnecessary doses of warfarin after orders to hold the medication, resulting in a significant medication error and an Immediate Jeopardy situation for the resident's health and safety.
Removal Plan
- Policy/procedure review/revision by the DON/designee.
- Licensed nurse education on facility policies regarding high-risk medication, anticoagulants, transcribing physician's orders, and notifying the physician when lab values not in the therapeutic range, and re-education on putting in appropriate hold orders.
- Licensed nurse education on appropriate transcription of putting medication on hold.
- Corrective action/one to one education with licensed nurse/Certified Medication Aide identified in deficient practice.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with COPD, anxiety, and PTSD had a PRN morphine order for severe pain related to COPD, but the CNO stated she did not know what the appropriate indication for the order should be. The facility failed to ensure the medication was administered with an appropriate clinical indication.
A resident with osteomyelitis, a clavicle fracture, and a history of addiction received changing orders for Suboxone and oxycodone, including concurrent use for pain and OUD. The DON stated she questioned why Suboxone and oxycodone were being given together because Suboxone can block oxycodone’s effects, and the MD stated a 10 mg oxycodone dose would provide only a placebo effect for a resident taking Suboxone.
A resident’s chlorhexidine mouthwash remained at the bedside after the order had expired, despite no current order being in place. Facility policy stated nursing staff would remove expired or discontinued meds from bedside stock, but observation found the prescription mouthwash on the bedside table with no lock box or locked drawer. An LPN was unsure why it had not been removed, and the DON confirmed the last order had ended and no new order had been obtained.
A resident with dementia, schizoaffective disorder, and anxiety disorder had a donepezil HCL order listed for “cognitive impairment” instead of dementia. RN and RNS both verified the order and stated the diagnosis used as the indication was incorrect, and the facility policy required a diagnosis to justify medication use.
A resident with overactive bladder was given Macrobid for a presumed UTI after staff reported dysuria, confusion, and increased urination, but the urine culture grew only 10,000-50,000 CFU/ml of E. coli, below the threshold used to define a symptomatic UTI. The record showed no clear evidence of urinary symptoms in the surrounding progress notes, and facility leadership confirmed the culture did not meet the amount of growth required to justify antibiotic use.
Failure to monitor anticoagulant therapy: A resident with quadriplegia, seizures, and HTN was prescribed apixaban 5 mg BID, but the EMR did not include an order for anticoagulant monitoring and nursing documentation did not show daily monitoring for side effects with administration. The care plan called for monitoring, documenting, and reporting signs of anticoagulant complications, and the DON and ADM acknowledged the missing monitoring order in the EMR.
Unclear Clinical Indication for PRN Morphine Order
Penalty
Summary
The facility failed to ensure medications were administered with an appropriate clinical indication for one resident reviewed for unnecessary medications. Resident #23 was admitted with multiple diagnoses including COPD, anxiety, and PTSD. The resident’s care plan, revised 3/2/26, stated to give medications as ordered by the physician. The physician orders included Morphine Sulfate 20 mg/mL, 0.25 mL by mouth every 6 hours as needed for severe pain related to COPD, initiated on 7/7/26. During interview on 7/9/26 at 2:45 PM, the CNO stated she did not know what the appropriate indication for the morphine order should be.
Unnecessary Concurrent Use of Suboxone and Oxycodone
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary medications. The resident was admitted with diagnoses of acute osteomyelitis of the right ankle and a fracture of the left clavicle, and the care plan identified a history of addiction with risk for substance use. The hospital discharge medication summary listed buprenorphine-naloxone 4 mg every 4 hours, lidocaine patches for pain, and methocarbamol 750 mg three times daily. Physician orders later showed multiple changes to the resident’s pain and OUD-related medications, including buprenorphine-naloxone for opioid use disorder, oxycodone ER 10 mg every 12 hours for moderate to severe pain, discontinuation and reordering of buprenorphine-naloxone, and then buprenorphine-naloxone every 4 hours for pain for three days followed by oxycodone ER 10 mg every 12 hours. During interviews, the DON stated Suboxone prescriptions were reviewed by Physician #1 and that she questioned why some residents were receiving Suboxone and oxycodone together because Suboxone can block oxycodone’s intended effects. The MD stated he worked closely with Physician #1, did not prescribe Suboxone or oxycodone, and said residents taking Suboxone would need high amounts of oxycodone to receive pain relief; he stated a 10 mg dose would provide only a placebo effect.
Unremoved Discontinued Mouthwash at Bedside
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs when chlorhexidine mouthwash was not discontinued from the resident’s bedside after the physician-ordered end date. Review of the facility policy for self-administration of medications stated nursing staff would rotate bedside stock and remove expired, discontinued, or recalled medications. Review of the resident’s active orders showed no current order for chlorhexidine mouthwash, and the MAR showed three past orders for chlorhexidine gluconate 0.12% mouthwash, each with an end date that had passed. The resident’s quarterly MDS showed a BIMS score of 15 out of 15, indicating no cognitive deficits, and her diagnoses included dental caries, right-sided hemiplegia, visual loss in the right eye, cognitive communication deficit, and a history of traumatic brain injury. During observation, a bottle of prescription chlorhexidine mouthwash was found on the resident’s bedside table while the resident was not in the building, and no lock box or lock on the bedside drawer was observed. An LPN stated the resident kept the mouthwash at her bedside and was unsure why it had not been removed when the order ended. The DON confirmed there was no current order for the mouthwash and that the last order had ended, and the Administrator stated there should have been an order to continue the mouthwash or it should have been removed from the bedside. The DON later confirmed no new order had been obtained and the medication should have been removed when the last order expired.
Incorrect indication documented for donepezil order
Penalty
Summary
The facility failed to ensure that one sampled resident was free from an unnecessary drug because the resident’s donepezil hydrochloride order did not list an accurate indication for use. Resident 57 was admitted with diagnoses including dementia, schizoaffective disorder, and anxiety disorder, and the MDS indicated severely impaired cognitive skills for daily decision making, along with extensive assistance needs for activities of daily living. The order summary showed donepezil hydrochloride 5 mg at bedtime ordered for “cognitive impairment.” During record review and interviews, RN 2 and RNS 1 both verified the order and stated that the indication was incorrect and should have been dementia rather than cognitive impairment. The facility policy on unnecessary drugs stated that medications should be carried out with dosage, route, frequency, and diagnosis to justify medication use.
Unnecessary antibiotic given for unsupported UTI
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when it administered Macrobid for a urinary tract infection that was not supported by the documented culture results. Resident 42 had a diagnosis of overactive bladder and had been seen for urinary frequency and urgency, with the Myrbetriq dose increased from 25 mg to 50 mg. Later, the provider documented frequency and burning sensations and ordered a urinalysis with reflex culture for dysuria, even though progress notes from the surrounding period did not show evidence of urinary frequency, urgency, or painful urination. The urinalysis was obtained and the facility was notified that it was positive for infection, after which Macrobid 100 mg twice daily for 7 days was ordered for a diagnosis of UTI. However, the urine culture final result showed 10,000-50,000 CFU/ml of Escherichia coli, which was below the 100,000 CFU/ml threshold referenced in the CDC NHSN LTC UTI criteria for defining a non-catheter associated symptomatic UTI. The facility administrator and infection preventionist confirmed that the culture did not meet the required amount of bacterial growth to constitute an infection necessitating antibiotic use. Progress notes after the antibiotic was started documented mixed urinary symptoms, including denial of burning or painful urination and reports that frequency had improved or subsided. Observations of the resident on subsequent days showed repeated trips to the bathroom and use of the toilet, including episodes of very frequent bathroom use within minutes of each other. During interview, facility leadership stated staff had reported the resident was more confused, had dysuria, and had increased urination before the provider visit, and that this information was relayed to the provider, leading to the urinalysis order.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that one resident's drug regimen was free from unnecessary medication by not monitoring the resident for side effects of apixaban. Resident #10 was a male admitted with diagnoses including quadriplegia, seizures, and hypertension, and his quarterly MDS showed a BIMS score of 15, indicating intact cognition. Physician orders dated 06/24/2026 showed he was prescribed apixaban 5 mg by mouth twice daily, and the orders did not address monitoring of the anticoagulant. The MAR showed the medication was administered as ordered from 06/01/2026 through 06/23/2026. The resident's care plan, dated 01/07/2026, identified that he was on anticoagulant therapy and included interventions to monitor, document, and report signs or symptoms of anticoagulant complications. However, review of the electronic medical record did not show nursing documentation of daily monitoring for side effects of the anticoagulant with medication administration. During interview, the DON stated the purpose of monitoring anticoagulation was to ensure there was no uncontrolled bleeding and acknowledged there was no order for monitoring in the EMR. The ADM also stated the resident did not have an anticoagulant monitoring order and that the DON was responsible for ensuring orders were entered into the EMR. The facility policy titled, Anticoagulation - Clinical Protocol, stated staff and physician would monitor for possible complications in individuals being anticoagulated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.