Failure to Ensure Resident Free from Significant Medication Errors with Warfarin Administration
Penalty
Summary
A resident with a diagnosis of deep vein thrombosis was admitted to the facility and prescribed Warfarin to treat and prevent blood clots. The physician ordered a PT/INR test to be performed, which was completed as scheduled. However, there was no evidence that the PT/INR results were reviewed or that the provider was notified of the results. Additionally, there was no documentation of a new Warfarin order for continued therapy following the test. As a result, the resident did not receive Warfarin doses on two consecutive days. Further review showed that a Coumadin Alert order, intended to ensure staff awareness and proper administration of Warfarin, was not transcribed until several days after the missed doses. Staff interviews confirmed the lack of documentation regarding the PT/INR results and the absence of a Warfarin order during the period in question. The Director of Nursing acknowledged the delay in transcribing the Coumadin Alert and confirmed the missed medication doses.