Failure to Ensure Proper Administration Route for Anticoagulant Medication
Penalty
Summary
Facility staff failed to ensure that a resident receiving anticoagulant therapy was free from significant medication errors. The resident, who had a history of a displaced intertrochanteric fracture of the left femur, anemia, and hyperlipidemia, was prescribed Lovenox to be administered subcutaneously for deep vein thrombosis prophylaxis. The physician's orders and the facility's policies clearly indicated that Lovenox should be given via the subcutaneous route. During medication administration, a licensed vocational nurse (LVN) was observed preparing to administer Lovenox to the resident. The LVN initially stated that the medication was to be given intramuscularly and was about to proceed with this incorrect route. Upon further review and verification, the LVN realized the error and acknowledged that the medication should be administered subcutaneously, as per the physician's order. The LVN also admitted to not checking the Medication Administration Record (MAR) prior to preparing the injection, which contributed to the near-miss error. Interviews with the LVN and the Director of Nursing (DON) confirmed that administering Lovenox intramuscularly would have been a significant medication error, as the correct route is subcutaneous. The facility's policies require staff to verify the medication, dose, and route against the MAR before administration, especially for high-risk medications like anticoagulants. The failure to follow these procedures resulted in a deficiency related to medication administration practices.