Failure to Prevent Significant Medication Error Due to Missed Anticoagulant Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as required by facility policy and state regulations. Review of the clinical record showed that a resident with diagnoses including high blood pressure, cancer, and left knee pain had a physician's order for daily subcutaneous injections of Fondaparinux Sodium, a blood thinner. The resident's Medication Administration Record for May 2025 indicated that the medication was not administered on two consecutive mornings due to the medication being pending delivery. Facility policy required that medications be reordered from the pharmacy at least three days before the last dose to ensure availability, and that all administrations be properly documented. During an interview, the Director of Nursing confirmed that the resident did not receive the ordered medication as required, resulting in a significant medication error for one of the residents reviewed.