Failure to Administer Prescribed Anticoagulant Due to Medication Access and Communication Lapses
Penalty
Summary
A deficiency occurred when a resident with diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon was not administered their prescribed apixaban 5 mg at night on two consecutive days following admission. The resident had intact cognition and was admitted with physician orders for several medications, including apixaban, dronabinol, folic acid, and oxycodone. Although apixaban was available in the facility's automated medication dispensing machine, the medication was not given as ordered on the nights in question. The failure to administer the medication was due to a combination of factors: the admitting LPN did not enter the physician medication orders before the end of her shift, and the night shift LPN did not have authorized access to the automated medication dispensing machine. Additionally, neither nurse notified the physician that the medication would not be administered. The DON confirmed that the nurse could have contacted her to obtain the medication, but this did not occur. Facility policy required medications to be administered per physician orders but did not provide guidelines for physician notification when medications were unavailable.