Failure to Administer Anticoagulant and Monitor Labs as Ordered
Penalty
Summary
The facility failed to ensure that physician orders for anticoagulant medication and required blood test monitoring were followed for a resident receiving Coumadin therapy. Specifically, the resident, who had diagnoses including dementia, heart failure, and a prosthetic heart valve, was prescribed Warfarin Sodium (Coumadin) with instructions for daily administration and PT/INR blood tests twice weekly. Record review showed that several doses of Coumadin were not administered on specific dates, with no documented reason for the missed doses and no evidence that the physician or nurse practitioner was notified. Additionally, a scheduled PT/INR lab test was not performed as ordered, again without documentation or notification to the appropriate medical provider. As a result of these missed doses and lab tests, the resident's PT/INR levels were found to be below the therapeutic range, prompting subsequent adjustments to the Coumadin dosage. Interviews with staff revealed that PT/INR testing was dependent on the availability of test strips, and if unavailable, samples were sent to the hospital. Facility policies required that all physician orders be implemented and that residents on Coumadin be monitored through regular blood testing, but these protocols were not consistently followed for this resident.