Failure to Administer Anticoagulant as Ordered and Notify Physician
Penalty
Summary
The facility failed to follow physician's orders for the administration of Lovenox (Enoxaparin Sodium Injection) for a resident who was admitted with a post-operative diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE). The hospital discharge summary included orders for Lovenox 100 mg to be administered subcutaneously every 12 hours. Review of the electronic medication administration record and physician orders revealed that the resident missed six doses of Lovenox over a four-day period, and there was no documentation that the physician was notified about the unavailability or delay of the medication. Interviews with the nurse supervisor and the director of nursing confirmed that nursing staff are expected to notify the pharmacy and the physician if a medication is unavailable, and acknowledged that the physician should have been contacted. Facility policy also requires the prescriber to be contacted when medication delivery is delayed or unavailable.