Failure to Complete Ordered INR Test for Resident on Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to complete an International Normalized Ratio (INR) test as ordered by the physician for a resident receiving anticoagulant therapy. The resident, who had a history of atrial fibrillation and was on warfarin, had fluctuating INR levels that required close monitoring. Physician orders specified that the resident's warfarin should be held and the INR rechecked on a specific date following an elevated INR result. Documentation review revealed that the warfarin was appropriately held, but there was no record of the required INR test being completed on the ordered date. Nursing staff could not confirm that the test was performed, and there was no lab result or documentation to indicate it was done. Interviews with facility staff, including the nurse assigned to the resident, the Nurse Practitioner, the DON, and the Administrator, confirmed that the INR test was missed and not documented as completed. The care plan for the resident included completing labs as ordered and reporting abnormal results, but the lack of follow-through on the physician's order for INR testing constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs and was properly monitored.