Failure to Administer Ordered Anticoagulant Due to Medication Management Lapses
Penalty
Summary
A resident with multiple diagnoses, including chronic obstructive pulmonary disease, osteoarthritis, rheumatoid arthritis, ESBL, idiopathic scoliosis, and a history of falls, did not receive physician-ordered Enoxaparin Sodium injections for DVT prophylaxis on three consecutive days. The resident was cognitively intact and reported missing doses at the beginning of the month, attributing the issue to a delivery error. Review of the medication administration record and nursing progress notes confirmed that the medication was not administered on those days due to it being unavailable or not delivered by the pharmacy. Despite the facility having an emergency pharmacy stock machine containing two syringes of Enoxaparin, nursing staff were either unaware of its availability or did not access it. The Director of Nursing confirmed that the medication was always stocked in the emergency machine and that a list of available medications was posted for staff reference. Facility policies required medications to be administered as ordered and reordered in advance to prevent lapses, but these procedures were not followed, resulting in the resident missing prescribed doses.