Failure to Follow Physician Orders for Anticoagulant Monitoring
Penalty
Summary
Nursing staff failed to follow physician orders for a resident who returned from the hospital with diagnoses including cerebral infarction, aphasia, hypertension, and atrial fibrillation. The resident required daily INR monitoring due to ongoing administration of Coumadin and Lovenox. Over several days, staff did not obtain the required blood samples for PT/INR testing as ordered. Documentation showed missed or inadequate blood draws, and there was no evidence that the physician was notified of these failures or the inability to obtain lab results. Despite the lack of INR results, the resident continued to receive anticoagulant medications as prescribed. The resident's medical record indicated multiple missed opportunities for lab draws, including instances where the lab was closed or the resident declined to go to the lab, but staff did not attempt to draw blood at the facility or notify the physician. Eventually, when a PT/INR was obtained, the result was critically high. Interviews with nursing staff and administrative personnel confirmed that the daily INR labs had not been completed as ordered. The facility was unable to provide a policy related to nursing services when requested.