Failure to Administer and Accurately Document Anticoagulant Medication
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to administer Heparin as ordered by the physician for a resident who was admitted with a displaced intertrochanteric fracture of the right femur and a fracture of the right lower leg. The physician's order specified that the resident was to receive Heparin 5000 units/mL, 1.0 mL subcutaneously every eight hours for deep vein thrombosis (DVT) prophylaxis. On the day of the incident, the resident attended physical therapy and was not present in her room at the scheduled medication time. The LVN did not administer the scheduled dose and mistakenly documented in the Medication Administration Record (MAR) that the dose had been given. Later that day, the resident reported to another LVN that she had not received her afternoon dose of Heparin and was experiencing swelling in her legs. Upon review, the second LVN confirmed with the first LVN that the dose had indeed been missed. The resident continued to complain of swelling, and her left lower extremity was observed to be swollen. The physician was notified, and a venous doppler was ordered but could not be performed due to the presence of a soft leg cast and brace. The resident was subsequently transferred to a general acute care hospital for further evaluation. At the hospital, the resident was assessed and diagnosed with extensive acute DVTs of the left lower extremity. Interviews with facility staff confirmed that the missed dose of Heparin was due to the resident being away at physical therapy and the proximity to shift change. The LVN acknowledged both the failure to administer the medication and the erroneous documentation. The facility's policy required medications to be administered as ordered and documented accurately, which was not followed in this instance.