Failure to Administer Anticoagulant Following Hospital Readmission
Penalty
Summary
A resident with a diagnosis of atrial fibrillation was admitted to the facility with physician orders to receive 5 mg of apixaban twice daily. Following a hospitalization for pneumonia, the resident was readmitted to the facility with discharge orders to continue apixaban. However, the medication was not administered from the date of readmission through several days afterward, as documented in the Medication Administration Record (MAR), which showed the medication was on hold without any nursing notes explaining the reason. The admitting nurse did not input the apixaban order upon the resident's return, and there was no physician order to hold the medication. The resident reported to a complainant that they had not received their blood thinner since returning from the hospital and expressed concern about being taken off the medication. Facility staff confirmed that the apixaban was not administered until several days after readmission, and the medication could have been accessed from the emergency medication kit if not available. The physician verified that the medication was not supposed to be held, and the error was acknowledged by facility staff as a serious medication error.