Failure to Clarify and Prevent Administration of Contraindicated Medications
Penalty
Summary
The facility failed to follow its own policy and procedures and did not ensure professional standards of practice were met when a resident with a diagnosis of nontraumatic intracerebral hemorrhage (ICH), hemiplegia, transient ischemic attack, and cerebral infarction was administered medications with known severe drug interactions. Specifically, the resident was given both Heparin and Aspirin, which triggered a drug interaction warning in the medication system due to the risk of enhanced anticoagulant effects. The medication administration record confirmed that both medications were administered on the same day, despite the presence of a severe interaction warning. Interviews with licensed nurses and the Director of Nursing revealed that staff were aware of the resident's diagnosis and the drug interaction warning but did not clarify the orders with the physician as required by facility policy. The pharmacist confirmed that the combination of Aspirin and Heparin is contraindicated in such cases and should have been clarified with the provider. The facility's policy states that any medication order believed to be inappropriate or associated with potential adverse consequences must be discussed with the attending physician or medical director, which was not done in this instance.