Failure to Ensure Unnecessary Drug Use Was Avoided for Anticoagulant Therapy
Penalty
Summary
A resident with multiple diagnoses, including unspecified dementia, bipolar disorder, schizoaffective disorder, and other chronic conditions, was found to be receiving heparin injections for VTE (venous thromboembolism) prophylaxis. The physician order sheet indicated that the resident was to receive heparin 5000 units subcutaneously every eight hours, and the medication administration record confirmed that the resident received this medication multiple times in June. However, a review of the resident's medical diagnoses and the Minimum Data Set (MDS) revealed no documented diagnosis of VTE or any other condition justifying the use of heparin. During interviews, the medical doctor stated that the resident was on heparin because it was started in the hospital and to prevent blood clots, particularly in non-ambulatory patients. However, the resident was observed to be ambulatory and able to transfer independently. The administrator confirmed that there was no current diagnosis supporting the use of heparin for this resident, and documentation from a nurse practitioner visit also did not provide a diagnosis for the continued use of the anticoagulant.