Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
A deficiency was identified when staff failed to administer medications as ordered for a resident with a history of wedge compression fracture of the lumbar vertebra, malignant neoplasm of the prostate, and prior cerebrovascular events. The resident was at risk for bruising and bleeding due to anticoagulant therapy. The medication administration record indicated an order for enoxaparin 0.7 ml, but the pre-filled syringes contained 0.8 ml, and staff were instructed to administer only 0.7 ml. However, review of records and direct observation revealed that staff administered the full 0.8 ml dose instead of the prescribed 0.7 ml on multiple occasions. On one occasion, a registered nurse was observed injecting 0.8 ml of enoxaparin and later confirmed the error upon reviewing the order. The resident's wife also reported witnessing a nurse in training administer the incorrect dose and voiced her concerns, which were dismissed by the staff member. Laboratory results showed an elevated INR following these incidents. Facility policy required verification of the correct dose prior to administration, but this was not followed, resulting in significant medication errors.