Failure to Notify Physician and HCP of Medication Error Involving Anticoagulant
Penalty
Summary
The facility failed to notify a resident's physician and activated Health Care Proxy (HCP) about a significant medication error involving the administration of nine additional doses of Eliquis (apixaban), an anticoagulant, due to a duplicate order entry. The resident, who was admitted with osteomyelitis and had a history of encephalopathy leading to HCP invocation, was prescribed Eliquis 2.5 mg twice daily for 30 days following a hospital discharge. However, the medication was entered into the electronic Medication Administration Record (eMAR) twice, resulting in the resident receiving double the intended doses over several days. The error was discovered when a surveyor identified the duplicate order and informed the Unit Manager (UM), who then discontinued one of the orders. Despite this discovery, there was no documentation in the medical record indicating that the resident's physician or HCP had been notified of the medication error. Additionally, the UM did not complete an incident report or conduct an investigation, only notifying the Assistant Director of Nursing (ADON) of the issue. Interviews with facility staff confirmed that the required notifications and documentation were not completed. The ADON acknowledged instructing the UM to notify the physician and discontinue the order but did not follow up to ensure this was done or complete a medication error report herself. The Director of Nursing (DON) also confirmed that there was no documentation of the error or required notifications in the resident's record, and that the facility's protocol for medication errors was not followed.