Failure to Obtain and Communicate Required Lab Results for Anticoagulant Monitoring
Penalty
Summary
The facility failed to obtain adequate blood samples for a resident who required daily INR monitoring following hospitalization, as ordered by the physician. The resident, who had a history of cerebral infarction, aphasia, hypertension, and atrial fibrillation, was prescribed Coumadin and Lovenox, both anticoagulant medications. Despite physician orders for daily INR testing, there were multiple days when blood samples were either not collected, not successfully obtained, or not processed due to lab closure or unsuccessful attempts. On several occasions, staff did not notify the physician about the missed or failed blood draws, and the resident continued to receive anticoagulant medications without the required laboratory monitoring. Documentation in the resident's medical record showed that on one day, no attempt was made to draw blood, and on another, two unsuccessful attempts were made without physician notification. On a subsequent day, the resident declined to go to the lab, and there was no evidence that staff attempted to draw blood at the facility or informed the physician. The following day, staff did not draw a sample because the lab was closed and again failed to notify the physician. Eventually, when the blood was drawn, the INR was found to be critically high. The facility's laboratory policy required timely and accurate lab testing, proper documentation, and communication, but these protocols were not followed in this case.