Failure to Timely Report and Address Medication Omission Leading to DVT
Penalty
Summary
A significant medication error occurred when a resident was admitted to the facility following a hospital stay for fractures and was prescribed an anticoagulant (Eliquis) as part of their discharge medications. Despite the hospital discharge summary and medication reconciliation order clearly listing the anticoagulant, there was no documented evidence that the medication was ordered or administered upon admission or during the resident's stay. The resident did not receive the prescribed anticoagulant from the time of admission until they were transferred back to the hospital. The omission was discovered after the resident developed edema in the lower extremity and was sent to the hospital, where they were diagnosed with deep vein thrombosis (DVT). Investigation revealed that a registered nurse had sought clarification regarding the anticoagulant order but did not ensure the medication was provided. The facility's documentation showed that the medication omission was not identified or addressed until after the resident's hospital readmission and diagnosis of DVT. Furthermore, the facility failed to report the significant medication error to the New York State Department of Health within the required timeframe. The Director of Nursing and the Administrator were notified of the incident several days after the resident's transfer, and there was uncertainty regarding which entity was responsible for reporting. The incident was ultimately reported to the State Agency, but not in a timely manner as required by state regulations and facility policy.