Failure to Monitor Anticoagulation Therapy and Maintain Therapeutic INR
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation and a mechanical heart valve replacement was admitted to the facility following a hospital stay. The resident was prescribed warfarin therapy and required weekly Prothrombin Time/International Normalized Ratio (PT/INR) monitoring to ensure therapeutic anticoagulation levels, as recommended for individuals with mechanical heart valves. However, the resident's electronic medical record did not document the diagnosis of a mechanical heart valve replacement, nor did it include a provider rationale for not maintaining the INR within the recommended therapeutic range for such patients (2.5-3.5). The facility failed to obtain the resident's PT/INR as ordered on a specific date, and there was no documented evidence that the provider was notified of the missed lab. The facility's policy required prompt reporting of lab values and provider notification if labs were missed, but this did not occur. Additionally, the resident's care plan did not address anticoagulation therapy or the need for monitoring related to the mechanical heart valve, and the diagnosis was omitted from both the diagnosis sheet and care plan. Three days after the missed PT/INR, the resident exhibited impaired speech and increased confusion, prompting transfer to the hospital. At the hospital, the resident was found to have a subtherapeutic INR (1.16) and was diagnosed with an acute stroke. Interviews with facility staff and providers confirmed that the lack of documentation and communication regarding the resident's mechanical heart valve and missed lab contributed to the failure to maintain appropriate anticoagulation, resulting in actual harm to the resident.