Failure to Hold Anticoagulant as Ordered Prior to Surgery
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following physician's orders regarding the administration of warfarin (Coumadin). The resident had a surgical procedure scheduled, and preoperative orders directed staff to contact the Coumadin Clinic or prescribing provider about when to hold the medication. A progress note specified that Coumadin should be held from a certain date until after the procedure. Despite these orders, the resident received Coumadin on two days when it should have been withheld. An administrative nurse confirmed that staff did not hold the medication as ordered by the physician. Review of the resident's medical record and medication administration record confirmed the medication was administered contrary to the documented orders, and this was acknowledged by facility staff during an interview.