Failure to Hold Anticoagulant After Critical Lab Value Due to Communication Breakdown
Penalty
Summary
The facility failed to recognize, identify, and confirm with a physician the need to discontinue or hold a Coumadin (warfarin) order for a resident who had a critical lab value. The resident, who had chronic atrial fibrillation and was on chronic anticoagulation therapy, returned from the emergency department with a significantly elevated INR and a large hematoma. Despite documentation in the hospital records to hold Coumadin for one week due to the elevated INR, the medication orders in the long-term care facility's electronic medical record remained unchanged, and the resident continued to receive the medication. Nursing staff did not question the continuation of Coumadin, nor did they contact the provider for clarification, even though the facility's policy required provider notification and holding the medication for elevated INR levels. Interviews with staff revealed a communication breakdown between the hospital and the LTC facility, resulting in the hold order not being transferred to the facility's EMR. Staff acknowledged that critical thinking and nursing judgment were not applied, and the Coumadin order was not included in the investigation of the resident's injury, which was attributed to the use of the sit-to-stand lift and the effects of anticoagulation. The facility's policy required prompt provider notification and action for elevated INR, which was not followed in this case.