Failure to Discontinue Anticoagulant as Ordered After INR Reached Therapeutic Range
Penalty
Summary
A review of facility policy, clinical records, and staff interviews revealed that the facility failed to administer medication as ordered by the physician, resulting in a significant medication error for one resident. The facility's policy required medications to be administered according to prescriber orders, including any specified time frames. A resident with diagnoses of atrial fibrillation and an arterial aneurysm was discharged from the hospital with an order to receive 50 mg of enoxaparin daily until the resident's INR reached a therapeutic range. Laboratory results showed that the resident's INR was within the therapeutic range on September 17, 2025. Despite the INR being in the therapeutic range, the Medication Administration Record indicated that enoxaparin was still administered on September 18 and 19, contrary to the physician's order. The DON confirmed that the medication should have been discontinued once the INR was therapeutic, but it was not, resulting in the resident receiving unnecessary doses. This failure to discontinue the medication as ordered constituted a significant medication error.