Failure to Accurately Administer and Manage Coumadin Therapy
Penalty
Summary
The facility failed to ensure that Coumadin was administered and managed according to physician orders and the resident's therapeutic INR goal. A resident with a history of atrial fibrillation and transient ischemic attack was admitted with orders for Coumadin and a target INR range of 2.0 to 3.0. Multiple errors were identified in the transcription and administration of Coumadin orders, resulting in missed doses on several occasions. Specifically, LPNs transcribed Coumadin orders to start on incorrect dates, causing the resident to miss scheduled doses on three separate days. Additionally, there were inconsistencies and delays in obtaining new Coumadin orders when INR results were outside the therapeutic range. On several occasions, the resident's INR was either above or below the target range, but no new orders were documented or implemented in a timely manner. There was also a documented instance where an APRN intended to increase the Coumadin dose but incorrectly entered a lower dose, which was then administered to the resident. Facility documentation and interviews confirmed that the resident's Coumadin therapy was not consistently managed to maintain the INR within the prescribed range. The facility's Coumadin protocol required accurate logging of INR results, current and new orders, and timely physician notification, but these procedures were not consistently followed. Both the APRN and physician acknowledged that Coumadin doses should not have been missed and that orders should have been transcribed accurately.