Failure to Administer Prescribed Anticoagulant Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of joint replacement surgery, use of an artificial hip joint, polyosteoarthritis, and long-term anticoagulant therapy did not receive their prescribed blood thinner medication, Rivaroxaban, for four days. The resident, who was cognitively intact, reported missing the medication and expressed concern about the risk of blood clots. Documentation in the Medication Administration Report confirmed that the medication was not administered on four specific days, with notes indicating the facility was waiting for pharmacy delivery. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, revealed that procedures existed for obtaining medications not immediately available, such as retrieving them from a medication dispensing machine or requesting a rush delivery. Despite these procedures, the resident's medication was not provided as ordered by the physician, and the facility's policies require medications to be administered according to physician orders. The failure to ensure timely administration of the blood thinner directly affected the resident.