Failure to Administer Anticoagulant as Ordered Due to Admission Order Transcription Error
Penalty
Summary
A deficiency occurred when a resident with a history of deep vein thrombosis, peripheral vascular disease, hyperlipidemia, anemia, and hypertension was admitted from the hospital with orders to continue Eliquis (apixaban) 5 mg twice daily. The hospital discharge note and physician's order both specified the need for this anticoagulant medication. However, the medication order was not transcribed into the Medication Administration Record (MAR) upon admission, resulting in the resident not receiving Eliquis for five days after admission. The omission was discovered during a chart review, and it was noted that the admitting nurse's checklist lacked a required second nurse signature. Facility policy required a second nurse to review and sign off on admission orders within 24 hours, but this did not occur. Interviews with staff confirmed that hospital discharge medication orders should be entered into the computer and reviewed according to policy, but this process was not followed, leading to the significant medication error.