Failure to Verify Discharge Orders and Monitor Anticoagulant Use Leads to Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to provide treatment and services in accordance with professional standards of practice for a resident who had recently undergone lumbar decompression and fusion surgery. The facility did not ensure that the admitting RN reviewed and verified the hospital discharge records with the attending physician, specifically regarding the start date for Plavix, an antiplatelet medication. The hospital discharge orders clearly indicated that Plavix was to be started nine days after admission, but the facility's licensed nurses began administering the medication immediately upon admission, based on an incomplete faxed medication list that lacked start dates. The facility also failed to provide continuity of care by not following the neurosurgeon's specific order to delay the initiation of Plavix. The medication was administered for four days prior to the intended start date, and there was no evidence that the nurses clarified the discrepancy with the attending physician. Additionally, the facility did not assess, monitor, or document the resident for signs and symptoms of bleeding, hematoma, or hemorrhage, despite the resident's recent spinal surgery and use of an antiplatelet medication, both of which increased the risk for such complications. As a result of these failures, the resident experienced a change of condition, becoming unresponsive and requiring emergency transfer to a hospital, where imaging revealed multiple intracranial hemorrhages. The resident subsequently died, with the immediate cause of death listed as nontraumatic intracranial hemorrhage. Interviews with facility staff and physicians confirmed that the medication was given earlier than ordered and that appropriate monitoring and verification of orders did not occur.
Removal Plan
- The DON and designee provided in-service education to all licensed nurses and direct care staff regarding reviewing and verifying any discrepancies with the ordering physician by clarifying the faxed medication discharge order and the GACH discharge papers that were given to the resident. In addition, clarify medication orders that are missing the start and end dates.
- The DON and designee provided in-service education to all licensed nurses and direct care staff regarding monitoring the resident status post-surgery and the use of anticoagulant therapy for potential side effects such as signs/symptoms of bleeding.
- The DON and designee provided in-service to the licensed nurses regarding: Review and verify GACH discharge orders with facility's attending physician. Status post-surgery residents with anticoagulant use and signs/symptoms of bleeding. Following GACH discharge orders. Any licensed staff, who were not present, the DON will do in-service education upon returning to work.
- Residents on anticoagulants were assessed for any signs/symptoms of bleeding, potential side effects of anticoagulant use and black box warning monitoring.
- The Registered Nurse (RN) Supervisor will check clinical alerts report daily for any COC and any signs/symptoms of bleeding.
- DON, ADON or RN Supervisor/designee will conduct medication reconciliation with the residents GACH discharge orders and admitting orders carried out by licensed nurse.
- Newly admitted residents will have random audits following GACH discharge orders and completion of medication reconciliation. Three residents weekly for four weeks, then two residents weekly for two weeks, then two residents a month for two months. Inservice would be given to licensed nurses involved. Findings will be presented in the monthly QAA meeting.
- DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) for the following: Review and verify GACH discharge orders with attending physician. Use of anticoagulant and its side effects. Following GACH discharge orders. PIP resulted in DON/ADON doing daily audits in reviewing compliance for following GACH discharge orders, continuity of care, use of anticoagulant and identification of potential adverse side effect of the medication.
- The Quality and Safety (QS) RN/Consultant will complete audits on medication reconciliation, the use of anticoagulants, and its side effects for newly admitted residents.
- ADM, DON or Designee will submit audit findings to QAA committee monthly until compliance is met.
- The facility will develop a QAPI-PIP for the use of anticoagulant to be submitted in the next QAA committee meeting.
- ADM and DON are responsible for implementing, monitoring and evaluating the Plan of Correction (POC).