Failure to Notify NP of Missed INR Lab for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to notify the Nurse Practitioner (NP) when a resident's ordered International Normalized Ratio (INR) test was not completed as scheduled. The resident, who had a history of atrial fibrillation and was prescribed warfarin, had an elevated INR of 4.0, prompting the NP to order the medication to be held and the INR to be rechecked on a specific date. Documentation showed that the warfarin was not administered during the specified period, but there was no record of the INR test being completed or its results for the ordered date. Nurse #1, who was assigned to the resident on the day the INR was to be checked, could not recall performing the test and confirmed that if the result was not documented, the test was not done. Interviews with the NP, DON, and Administrator confirmed that the INR was not checked as ordered and that the NP was not notified of the missed lab. The NP stated that she expected to be informed if the lab was not completed, especially given the resident's fluctuating INR levels and the need for close monitoring. The DON and Administrator also indicated that they were unaware the lab had been missed and agreed that the NP should have been notified. The lack of notification and failure to follow through with the ordered lab test constituted the deficiency.