Failure to Obtain Ordered Laboratory Test for Anticoagulation Monitoring
Penalty
Summary
The facility failed to obtain a laboratory test as ordered by the physician for one resident who was receiving anticoagulation therapy. According to facility policy, the charge nurse is responsible for obtaining physician orders for pertinent labs and notifying the physician of results, specifically for residents on medications such as warfarin. The resident in question had a history of atrial fibrillation and cerebral infarction, was cognitively impaired, and required assistance with care needs. After a critically high PT/INR result, the resident's anticoagulation therapy was adjusted, and a repeat PT/INR was ordered and completed the following day. Subsequently, the physician ordered another INR blood test to be performed on a specific date. However, there was no documented evidence that this laboratory test was completed as ordered. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the test was not performed as required by the physician's order.