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F0760
J

Failure to Administer Anticoagulant on Admission Leads to Harm

Auburn, New York Survey Completed on 10-29-2025

Penalty

Fine: $21,645
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident was admitted to the facility following a hospital stay for a left femoral fracture. The hospital discharge summary and medication reconciliation order report both indicated that the resident was to receive Eliquis, an anticoagulant, at a specified dose. However, upon admission, the medication was not ordered, and the resident did not receive any anticoagulant therapy during their stay at the facility. The admitting nurse accessed the hospital records and noted the medication reconciliation order form but did not review the discharge summary or clarify questions about the anticoagulant order. The nurse placed the medication reconciliation form on the nurse practitioner's desk without notifying them of any concerns. The nurse practitioner reviewed and signed off on the orders entered into the computer but did not compare the discharge summary and medication reconciliation order form against the orders entered. A third nurse, responsible for the final check, only reviewed the orders in the medical record and did not reference the original hospital documents. As a result, the omission of the anticoagulant was not detected by any of the staff involved in the admission process. The resident subsequently developed edema in the lower extremity and was sent to the hospital, where a deep vein thrombosis was diagnosed. Interviews with facility staff revealed that the established protocols for medication reconciliation and double-checking high-risk medications, such as anticoagulants, were not followed. The failure to clarify and verify the resident's medication orders led to the resident not receiving a critical medication, resulting in actual harm.

Removal Plan

  • Educate nursing staff to not view or print the discharge summary or medication reconciliation order form until a resident is discharged from the hospital.
  • Transcribe medication from the discharge summary or medication reconciliation order form by the admitting nurse for each new admission or re-admission.
  • Review medication orders by the advanced practice provider.
  • Review medication orders by a second nurse.
  • Review medication orders by the Director of Nursing.
  • Review medication orders by a licensed pharmacist.
  • Provide staff education based on an education outline.
See complete original report
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