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F0760
J

Failure to Identify Missing Admission Orders Leads to Omission of Anticoagulant

West Chester, Ohio Survey Completed on 11-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure a resident was free from significant medication errors during the admission process. Upon admission from another skilled nursing facility, the resident's transfer documents were incomplete, with several pages missing from the faxed admission orders, including those listing current medications. The admitting nurse entered medication orders from the incomplete fax without noticing the missing pages, and the same incomplete set of orders was provided by the resident's family upon arrival. The missing documentation resulted in the omission of an order for apixaban, an anticoagulant medication that the resident had been receiving at the previous facility for atrial fibrillation. Multiple staff members, including the admitting nurse, a nurse practitioner, and a second nurse who double-checked the orders, failed to identify that the admission orders were incomplete and that the anticoagulant was missing from the medication list. The facility's process required verification of orders and confirmation that all pages were received, but this was not done. The resident's care plan included a diagnosis of atrial fibrillation but did not address anticoagulant therapy, and the medication administration record showed that apixaban was not administered during the resident's stay. The resident subsequently developed symptoms of shortness of breath and tachycardia, prompting transfer to a hospital where a diagnosis of pulmonary embolism was made. Hospital staff confirmed with the facility that the resident had not received apixaban since admission. Interviews with facility staff revealed that the error was not detected during the initial review or subsequent verification of orders, and the omission was only discovered after the resident's hospitalization.

Removal Plan

  • Resident #148's medical record was reviewed by the DON, including a review of the medication list from admission and the admission orders transcribed into the EMR.
  • CNE #200 conducted a review of Resident #148's medical record including physician orders, care plans, and administration records.
  • Regional MDS Nurses #220, #230, #235, and #240 completed an audit of all residents admitted in the last 60 days to ensure admission orders were transcribed correctly into the medical record.
  • Any concerns noted during the audit were reviewed with NP #360 and orders updated as needed by licensed nurses.
  • Regional MDS Nurses #220, #230, #235, and #240 verified that all pages of admission orders from transferring facilities were received/present.
  • The DON or designee completed an audit of current residents with atrial fibrillation diagnosis and residents receiving anticoagulant medications for appropriateness.
  • NP #360 reviewed current residents with atrial fibrillation diagnosis and residents receiving anticoagulant medications for appropriateness.
  • Nurse Educator #280 completed a medication administration observation.
  • RN #15 and RN #16 were immediately provided education by the DON, including ensuring admitting orders are received and transcribed into the medical record, that all pages of the orders are received, and hard copy of the orders are received upon resident's arrival.
  • Licensed nurses were provided with an additional in-service education by the DON and ADON #100, including ensuring admission medication orders are reviewed and transcribed into resident medical records, that all pages of the orders are received, and that a hard copy of orders is received upon resident's arrival.
  • A performance improvement (PI) audit worksheet was implemented to verify residents' admitting orders are transcribed completely (including all pages are verified) into the medical record.
  • The PI audit is being completed by the DON or designee for any residents admitting to the facility for the previous day, daily for seven days, then three times per week for four weeks, then weekly for four weeks, and then monthly.
  • The results of the PI worksheet will be reviewed by the QAPI team.
  • Quality Assurance meetings were held with the Administrator, Medical Director, the DON, CNE #200, Regional Nurse #350, and Consultant Pharmacist #400.
  • Five additional medical records were reviewed with no concerns for significant medication errors identified.
See complete original report
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