Failure to Prevent Significant Medication Errors Due to Duplicate and Outdated Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Warfarin (Coumadin). The resident, who had diagnoses including dementia and muscle weakness, was prescribed alternating doses of Warfarin based on specific days of the week. On September 17, a new one-time order for 5 mg of Warfarin was received, with instructions to resume the prior alternating schedule afterward. However, when the nurse entered the new order, she also entered new standing orders for the alternating doses but did not discontinue the previous, duplicate orders. This resulted in the electronic medication record displaying multiple active Warfarin orders, leading to the resident receiving higher than prescribed doses on several consecutive days. Additionally, after the resident was hospitalized and returned with a new order to restart Warfarin on a specific future date, the medication was administered before the prescribed restart date. The medication cart was also found to have a prepared dose for administration on a day when the order specified the medication should be held. Staff interviews confirmed that nursing staff are responsible for reviewing and discontinuing outdated or duplicate orders in the MAR, but this was not done, resulting in the administration of incorrect doses and timing of Warfarin.