Failure to Maintain Therapeutic INR Levels and Timely Coumadin Management
Penalty
Summary
The facility failed to ensure that a resident receiving Coumadin (Warfarin) therapy had their INR levels maintained within the physician-ordered therapeutic range of 2.5 to 3.5. The hospital discharge summary specified Coumadin dosing and required INR monitoring every other day, with dose adjustments as needed. However, clinical record review revealed that INR tests were not consistently performed as ordered, and Coumadin doses were not always administered according to the prescribed schedule. There were multiple days when the resident did not receive any Coumadin, and INR results were frequently below the therapeutic range without timely intervention or dose adjustment. Documentation on the Coumadin Tracking Form was inconsistent and sometimes contained conflicting information regarding current doses, new orders, and next INR test dates. There were also instances where new orders were not obtained or acknowledged by a physician or APRN, and INR results were not acted upon in a timely manner. Interviews with clinical staff confirmed that the resident's INR levels were not maintained within the therapeutic range, and that the management of Coumadin therapy was not efficient or consistent with the facility's own Coumadin protocol policy. The resident had significant medical conditions, including cerebral infarct with hemiplegia, atrial fibrillation, and antiphospholipid syndrome, all of which increased the importance of maintaining therapeutic anticoagulation. Despite these risks, the facility did not provide adequate monitoring or management of the resident's Coumadin therapy, resulting in significant medication errors as identified by both facility staff and external reviewers. The deficiency was cited as Immediate Jeopardy due to the failure to maintain the ordered therapeutic INR range and to ensure timely and appropriate medication administration and monitoring.