Failure to Timely Continue Physician-Ordered Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure the continuation of a physician-ordered medication for a resident with a history of pulmonary embolism and peripheral vascular disease. The resident was supposed to receive Warfarin, a blood thinner, at a dose of 3mg as ordered by the primary care physician following a lab result. However, the order for Warfarin was not entered into the Medication Administration Record (MAR) until four days after the physician's order, resulting in the resident missing four consecutive doses of the medication. Interviews and record reviews confirmed that the lapse was not identified or addressed by nursing staff during this period. The LPN responsible for entering the order did not do so promptly, and the Director of Nursing was unable to explain why the medication was not continued as ordered. The primary care physician confirmed that the order was given but not implemented until several days later, and there was no documentation of communication or clarification regarding the missed doses during the gap.