Failure to Monitor Anticoagulant Therapy Leads to Hospitalization
Penalty
Summary
The facility failed to obtain physician-ordered laboratory testing for a resident who was receiving Warfarin for a diagnosis of pulmonary embolism. Despite having a physician order dated 4/23/25 to check PT/INR levels weekly, the resident's PT/INR was not monitored as required. The last PT/INR test was completed on 3/26/25, and no further tests were performed after that date, even though the resident continued to receive Warfarin. This lapse in monitoring was identified when the resident was admitted to the hospital with a supratherapeutic INR greater than 10, well above the target therapeutic range of 2-3. Hospital records documented that the resident suffered from acute blood loss anemia, probable gastrointestinal bleed, and required reversal of Warfarin with Kcentra, as well as multiple blood transfusions. The resident's family member expressed concern that the required INR checks were not being performed, and the attending physician confirmed that the weekly monitoring order had been given but not followed. Facility staff interviews and record reviews confirmed that the PT/INR tests were not conducted as ordered, and the Director of Nursing acknowledged that the tests should have been performed but were not. The facility's own anticoagulant policy required regular monitoring of PT/INR for residents on Warfarin, but this was not adhered to in this case, resulting in the resident experiencing significant medical complications.
Removal Plan
- Audit of all resident laboratory orders was completed by Director of Nursing.
- Audit of all residents that have physician orders for Warfarin were identified and have active lab orders for PT/INRs to monitor for therapeutic effectiveness was completed by Director of Nursing.
- Facility licensed nursing staff were educated by phone or in person in the following categories: Obtaining laboratory testing as ordered by the physician, with special consideration for those residents on Warfarin by Director of Nursing.
- Audit of all scheduled labs was completed, including PT/INRs by Director of Nursing.
- Audit of all residents with Warfarin medication orders were ensured to have scheduled laboratory testing of PT/INRs to monitor for therapeutic effectiveness by Director of Nursing.
- Director of Nursing initiated a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary.
- Licensed agency staff will not work at the facility until they are educated by the Director of Nursing/Designee on the importance of ensuring PT/INR levels are ordered with Warfarin to monitor for therapeutic effectiveness.
- The facility will educate all Agency and Facility licensed nursing staff on a quarterly basis and during orientation on the order process for labs, with emphasis on the need for therapeutic monitoring for effectiveness for residents with medication orders for Warfarin, by the Director of Nursing or Designee.
- The Director of Nursing or designee has put into place a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary.
- The Director of Nursing or designee will complete random audits of scheduled laboratory testing as ordered by the physician, with special consideration for those residents on warfarin until compliance is achieved.
- Results of the above reviews will be discussed at a weekly quality assurance meeting that the Administrator is the head of/holds and will provide additional education as needed and implement interventions for improvement until resolution.