Missed Warfarin Doses Due to Failure to Resume Order After Lab Results
Penalty
Summary
A deficiency occurred when the facility failed to write an order to resume warfarin for a resident following receipt of laboratory results, resulting in the resident missing three consecutive doses of the anticoagulant. The resident, who had a history of stroke, left-sided hemiplegia, and heart disease, was admitted on warfarin therapy and was cognitively intact. The facility's warfarin protocol required regular PT/INR monitoring and specific dose adjustments based on lab results. After a PT/INR result was received, the Unit Manager believed she had written an order to increase the warfarin dose but, upon review, found that no such order had been entered. Consequently, the resident did not receive warfarin for three days. Interviews with staff revealed that the Unit Manager was responsible for reviewing PT/INR results and adjusting medication doses according to protocol. The NP confirmed that the resident had difficulty maintaining a therapeutic PT/INR and required frequent dose adjustments. The DON and Administrator both stated that they expected staff to follow the warfarin protocol and ensure orders were entered as required. The failure to enter the new warfarin order led directly to the missed doses for the resident.