Failure to Administer Prescribed Warfarin Doses
Penalty
Summary
A deficiency occurred when a resident receiving Warfarin therapy did not receive prescribed doses of the medication on two consecutive days. The resident, who had a history of atrial fibrillation, hypertension, and a cardiac pacemaker, was admitted with physician orders for specific Warfarin dosing and regular PT/INR monitoring. Documentation showed that the resident's PT/INR was within the therapeutic range prior to the missed doses, and the physician had ordered continuation of the Warfarin regimen with follow-up lab testing. However, review of the Medication Administration Record (MAR) revealed that the resident did not receive Warfarin on the specified dates, and there was no evidence of a Warfarin order being implemented on one of those days. Subsequently, the resident's PT/INR dropped below the therapeutic range, as confirmed by lab results. The Assistant Director of Nurses acknowledged during interview that the resident missed the Warfarin doses on the identified dates.